PURCHASE CARD LOG Cardholder Approving Official BILLING CYCLE ENDING PAGE 8th of MONTH YEAR Name: Phone: Order# PURCHASE CARD STATEMENT Vendor: ORDERED RECEIVED Dispute Tracking Funds Order Date Name Address Requisition Qty Unit Receipt Statement Credit Data Statement Total Description Telephone or 2785 # & Price Date Date, Due Dispute Date & Price Of Unit Reference Or Form $ Credit $_____ (Including MAC Supplies and Services Name of Vendor of Due Number & # Faxed or (Include if Discount, SOC (CQ #) Representative Issue Date partial $ Amount Items To # Items Running Shipping (&Taxpayer ID #, If 1099 buy) Billed Due Citibank Received Balance recept) & Handling)
PURCHASE CARD LOG Cardholder Name: Phone: Approving Official BILLING CYCLE ENDING 8th of MONTH YEAR PAGE Order# Vendor: Name Address Telephone Name of Vendor Representative (&Taxpayer ID #, If 1099 buy) Description Of Supplies and Services ORDERED RECEIVED PURCHASE CARD STATEMENT Dispute Tracking Funds Order Date Requisition or 2785 # Qty & Unit of Issue Unit Price Total Price (Including Discount, Shipping & Handling) 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 #)
exhibit600-40-5.docx