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No. Limit to 20 spaces Ref/Inv. Date IRS Amount Indicator-Dept. AC 1171 Rev 10/96 STATE OF NEW YORK Originating Agency Payment Date MM DD / YY Voucher No* Interest Eligible Y/N Orig. Type Statistic Address Limit to 30 spaces 5 Ref/Inv* No* Limit to 20 spaces Ref/Inv* Date IRS Amount Indicator-Dept. City Limit to 20 spaces Limit to 2 spaces State Indicator-Statewide Amount Date Check or Description of Charges Paid If Personal Service show name title period covered Dollars State Aid Program or Ap ...

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