TOWNSHIP OF JACKSON 95 WEST VETERANS HIGHWAY JACKSON, NJ 08527 TEL (732) 928-1200

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VENDOR VENDOR #: ORDER DATE: REQUISITION NO: DELIVERY DATE: STATE CONTRACT NO: F.O.B. TERMS:

L VENDOR #: THIS ORDER IS TAX EXEMPT PER N.J.S.A. 54:32B-9(a)

TAX EXEMPT ID #21-6004702

QUANTITY/UNIT	DESCRIPTION	ACCOUNT NO.	UNIT PRICE	TOTAL COST
1	Return Of Tree Replanting Escrow Block: Lot: Address: Date:	T-12-56-851-002-817
VOUCHER COPY - SIGN AT X AND RETURN TO THE PURCHASING DEPARTMENT WITH YOUR INVOICE VENDOR'S CERTIFICATION & DECLARATION I do solemnly declare and certify under the penalties of the law that the within bill is correct in all its particular; that the articles have been furnished or services rendered as stated therein; that no bonus has been given or received by any person or persons within the knowledge of this claimant in connection with the above claim; that the amount therein stated is justly due and owing; and that the amount charged is reasonable one. X CLAIMANT TITLE DATE TAX I.D. OR SOCIAL SECURITY NO. INCORPORATED? ☐ YES ☐ NO	MUNICIPAL CERTIFICATION I, having knowledge of the facts; certify that the materials and supplies have been received or the services rendered; said certification being based on signed delivery slips or other reasonable procedures. SIGNATURE DATE	RECEIVED SIGNATURE DATE CERTIFICATION This is to certify that adequate funds are available for the purchase of the above mentioned services or materials and are appropriated under the current budget line listed above. CHIEF FINANCIAL OFFICER DATE ADMINISTRATOR APPROVAL