PARTIAL PAYMENT REQUEST

Date: May 12, 2010	Vendor #

This form MUST be attached to every invoice that is to be partial paid to assure accurate records of payment. Please attach this form on TOP of the invoice or invoices to be paid. If there is more than one invoice being paid on the same purchase order, only one (1) form is needed. Also, put the total payment to be made on the form.

The invoice must be signed certifying the items, services or improvements have been received and that the quantities, quality and pricing have been verified. The department designee shall sign this form authorizing payment.

VENDOR

P.O. NUMBER

CONTRACT #

AMOUNT OF PAYMENT

DEPARTMENT APPROVAL

IS THIS PAYMENT A WIRE TRANSFER? Yes No (Put an “X” in the box that applies)

Fund Code Disbursement

Item #

Fund

Dept	Sub-

Dept

Acct	Sub-

Acct

Proj	Sub-

Proj

Amount

PLEASE CHECK IF THIS IS THE FINAL PAYMENT

FOR PURCHASING USE ONLY

Certified Payrolls Received (if applicable)	YES

Revised 09/10/2009

Partial Payment Form

PARTIAL PAYMENT REQUEST

Brenda McBee

2009-10-08

City of Hamilton - Information Technology Department