ABCDEFGHIJKLMNOPQRSTUVWXYZ
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 POHNPEI STATE GOVERNMENT
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MISCELLANEOUS PAYMENT FORM
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 Fiscal Year:2024
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DATE:CONTROL NO.
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TO:
Director, Depatment of Treasury & Administration
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FROM:
Requesting Department
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(Vendor)
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Please process payment in the amount of
$to:
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for services rendered to the state Government or as other wise requested as follows:
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(Justify the purpose of the payment and attach supporting documents)
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 Finance Certification/Compliance
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Prepared by:NameFinance Certification
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TitleDateDate
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Reviewed by:Name
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TitleDateACCOUNT NO.AMOUNT
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I hereby certify that the goods or services by this payment
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request have been duly received or rendered to the
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Government and I hereby approve payment for such
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goods or services for the amounts stated above.
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Allottee Approval:
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Name & Signature
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Date
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Allottee Title
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TitleTOTAL $ -
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