PURCHASE CARD LOG - U.S. Department of the Treasury



|PURCHASE CARD LOG |Cardholder |Approving Official |BILLING CYCLE ENDING |PAGE |

| | | |8th of MONTH YEAR | |

| |Name: | | | |

| |Phone: | | | |

| | | | | | |

|Order# |Vendor: | |ORDERED |RECEIVED |PURCHASE CARD STATEMENT |Funds |

| |Name |Description | | |Dispute Tracking | |

| |Address |Of | | | | |

| |Telephone |Supplies and Services | | | | |

| | | | | | | |

| |Name of Vendor Representative | | | | | |

| |(&Taxpayer ID #, If 1099 buy) | | | | | |

|Order Date | | | | | | |

Requisition

or 2785 # | | |Qty

&

Unit of Issue |Unit

Price |Total

Price

(Including

Discount,

Shipping &

Handling) |

Ship-ment

Due

Date |Receipt

Date

(Include if

partial recept) |Statement

Date,

Reference

Number &

$ Amount

Billed |Credit

Due

Or

# Items

Due |Data

Dispute

Form

Faxed

To

Citibank |Statement

Date &

$ Credit

or

# Items

Received |

$_____

Running

Balance | |MAC

SOC (CQ #) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

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