Payee
DBA/Alias
Address
City
Invoice #
Invoice Date
Project
County

For Property Owner Payments,
Approved Offer Amount:
Alternate Offer Amount:

Distribution
Description	Area	Account Number	Func	Object	Fund	Project Number	Part	Tract	Parcel	Amount
Total Cost

Approved ___________________________ Region Engineer

_______________________________ Right of Way Bureau Chief

I hereby certify that the within account is correct and just and that

Sworn and subscribed before me this

___ day of ______________ 20 ___

_____________________________ Notary Public

Paid by State Warrant No.___________________________ Voucher No. _____ _____ Date _________________ Recommended for Approval Right-of-Way Manager Payment therefor has not been received.

[Notary Stamp]