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COUNTY OF CORTLAND (DESCRIPTION LIMIT TO 30 CHARACTERS) SUMMARY AMOUNT TOTAL (VENDOR OR CLAIMANT) (TITLE) OFFICE USE ONLY ACCT.NO AMOUNT ENCUMBRANCE NUMBER CLOSED DEPARTMENT HEAD OFFICE USE ONLY AUDITOR DATE AUDITED COUNTY USE ONLY (Rev. 3/4/10) CLAIM NO : CHECK NO : DATE: CLAIMANT : ADDRESS : : CITY/ST/ZIP: CLAIMANT REFERENCE NUMBER REFERENCE NUMBER WILL APPEAR ON CHECK DEPT. NO. DEPT. NAME: FOR DEPARTMENT HEAD APPROVAL I HEREBY CERTIFY, that the merchandise, materials, or articles enumerated in the above account have Been received, and the service specified performed; That they were necessary for, and have been, or will be applied to the use of the above department.