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NAME 30 ADDR 30 Claimants Name X By Signature Date Title DEPT. GOODS OR SERVICES DELIVERED TO VENDOR S PAYMENT TERMS DATE DELIVERED ITEMIZATION UNIT PRICE AMOUNT TOTAL CLAIMED For Nassau County Department Use Only Please note that only one invoice is payable per claim voucher. This must be signed and dated by an authorized person within your organization. Claim vouchers not properly certified will be returned to you unpaid. 9 Destination - Indicate to which Nassau County department the goods or ...

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