ftoo,
/' ' '/ ' ' V'' *>\v
' 'J*.
' I ' | pi \ • ( SEP 26 1538 }
^*S"^siAjBR A
APPENDIX B
TO
HANDBOOK OF PROCEDURES
FOR
STATE WORKS PROGRESS ADMINISTRATIONS
APRIL 15, 1938
WPA FORMS
COMPENSATION FORMS
STANDARD FORMS
TREASURY FORMS
X\
WORKS PROGRESS ADMINISTRATION
Harry L. Hopkins, Administrator
1734 New York Avenue, N. W.
Washington, D. C
>72.2
APPENDIX B
WPA FORMS
Appendix B
WPA 144a
Face and Reveree
«is
oSS
IDENTIFICATION NO.
ALIEN DECLARED INTENT
PRIOR TO JUNE U. 1917
SUBSEQUENT TO "
DATE OF BIRTH
NYA COLOR OR RACE
LAST NAME (PRINT)
HOW REACH BY PHONE
RELIEF DISTRICT HEIGHT WEIGHT
RELATIONSHIP TO HEAD
FULL NAME OF HEAD
PHYSICAL DISABILITY. IF ANY
SPEAK BEAD WHITE WORK QUALIFIED FOR
EDUCATION
HIGHEST YEAR COMPLETED
012345678
9 10 11 12
COLLEGE
12 3 4
ADDITIONAL TRAINING
PRIMARY CLASSIFICATION
SECONDARY CLASSIFICATION
SUPERVISORY EXPERIENCE
OTHER QUALIFICATIONS. EXPERIENCE OR COMMENTS
WPA Form 144a
(Revised)
INDIVIDUAL OCCUPATIONAL CLASSIFICATION RECORD
Description Actual site 8 by 5 inches) card, printed face
end reverse.
Routine Original only, maintained by Division of Employment
Instructions for Preparation See Handbook of Procedures,
ehapter XIII, seotion IT
Printed form supplied on request by Works Progress Admin¬
istration, Washington, ^ |
PRIVATE EMPLOYMENT RECORD
EMPLOYER—LAST REGULAR JOB
POSITION HELD AND DUTIES
LENGTH OF SERVICE
ADDRESS
DATE LEFT
KIND OF BUSINESS
RATE OF PAY
EMPLOYER
POSITION HELD A'NO DUTIES
LENGTH OF SERVICE
ADDRESS
DATE LEFT
KIND OF BUSINESS
RATE OF PAY
EMPLOYER
POSITION HELD AND DUTIES
LENGTH OF SERVICE
ADDRESS
DATE LEFT
KIND OF BUSINESS
RATE OF PAY
COMMENTS: WPA WORK EXPERIENCE
□ATE LEFT WPA
FOB PRIVATE EMPLOYMENT WITH—
REASON FOR TERMINATION
Appendix 8
WPA 150
WPA FORM 150
WORKS PROGRESS ADMINISTRATION
MONTHLY REPORT OF SPONSORS' EXPENDITURES FOR
WPA WORK PROJECTS
State
Month , 193
l|ne project
no» classification
(0 (2)
Cumulative Through
increase from previous
Month's Report
Total
(3)
Labor
(4)
non-
Labor
(5)
Total
(6)
labor
(?)
non-
labor
(8)
1 all projects
2 federal project no. i
3 Other wpa Work projects
$
$
$
$
$
$
MEMORANDUM
4- Amount of ca§h deposited by sponsors with the u. s. treasury Department
through . $
5 Encumbrances against sponsors' cash deposits
6 unencumbered cash balance
Prepared by
(title)
Approved
(State Statistician)
Approved_
(State Administrator)
(Date Submitted)
WPA Form 150
MONTHLY REPORT OF SPONSORS' EXPENDITURES
FOR WPA WORK PROJECTS
Description Actual sire 8 by loj inches; 1 page, face only.
Routing Original and three copies as follows: original and
first oopy to Division of Research, Statistics and Records,
Washington, D. C.; seoond copy to Regional Field Repre¬
sentative; third copy retained by State Works Progress
Administration.
Instructions for Preparation See Operating Procedure No. S-2.
Form to be duplicated by State Works Progress Administration.
Appendix 6
WPA 151
WPA form 151
WORKS PROGRE88 ADMINISTRATION
MONTHLY REPORT OF SPONSOR'S EXPENDITURES
FOR NY A WORK PROJECTS
State
Month ,193 .
L ine
no.
(d
Item
(2)
cumulative
Through
o)
increase from
Previous Month's
Report
(4)
1
TOTAL
$
$
2
Labor
3
non-labor
MEMORANDUM
4 /mount of cash depos iteo by sponsors with the
U. S. Treasury Department through
$
5 Encumbrances against sponsors' cash
deposits
6 Unencumbered cash balance
Prepared by.
(TITLE)
Approve d
(State Statistician)
Approved
(date Submitted) (State Administrator)
WPA Form 151
MONTHLY REPORT OF SPONSORS' EXPENDITURES
FOR NYA WORK PROJECTS
Description Actual size 8 by lOg inches; 1 page, faoe only.
Routing Original and four copies as follows: original and
first copy to Division of Research, Statistics and Records;
second copy to Regional Field Representative; third copy to
State Youth Director; fourth copy retained by State Works
Progress Administration.
Instructions for Preparation See Operating Procedure No. S-2.
Form to be duplicated by State Works Progress Administration.
Appendix B
WPA 352
wpa norm iaa
WORKS PROGRESS ADMINISTRATION
MONTHLY REPORT OF HOURS WORKED AND EARNINGS ON WPA WORK PROJECTS
State Month — , 193...
Limb
No.
(l)
pftoobam amd ubban Abba
(2)
IIOVM WOHKBD
eabkim08
Total
O)
Certified
(4)
Ncm certified
<«>
Total
(8)
Certified
<7>
Noaoertlflod
(8)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
10
Stats Summary
$
$
$.
Selected Urban Areas
(Till#)
Stale Statistician.
Stale Administrator.
Prepared by
Approved
Approved... ....
(Date submitted)
«. ■.mrmnmnnimii omca lfl—(ma
WPA Form 162
MONTHLY REPORT OF HOURS WORKED AND
EARNINGS ON WPA WORK PROJECTS
Description Aotual site 8 by 10j inches; 1 page, printed
faoe only.
Routing Original and three ooples as follows: original
and first copy to Division of Research, Statistics and
Records, Washington, D. C.; aeoond copy to Regional
Field Representativei third oopy retained by State Works
Progress Administration.
Instructions for Preparation See Operating Procedure No. S-4.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix B
WPA 153
WPA Form 158
WORKS PROGRESS ADMINISTRATION
MONTHLY REPORT OF EMPLOYMENT, HOURS WORKED, AND EARNINGS
ON THE NYA STUDENT AID PROGRAM
State .........
Month —, , 103....
Tm OF biodimi Aro
<a>
Nuans& or PxhsOMB
No.
w
Schools
(3)
Total
«>
Male
<«>
Female
<«>
WOBUD
cn
<B)
2
3
4
5
t
i i
■ 1
6
Total ...
6
" Only data for persons aided from the special Negro Graduate Aid fund are included on this line. Negroes are included on
line 4 if aided from the Regular Graduate Aid fund.
* This total includes — cooperating institutions in which both college aid and graduate aid were extended during the
period covered by this report.
Prepared by .
Approved
Stale Statistician.
(Date submitted)
Approved .
State Administrator.
WPA Form 153
MONTHLY REPORT OF EMPLOYMENT, HOURS WORKED AND EARNINGS
ON THE STUDENT AID PROGRAM
Description Actual size 8 by 10^ inches; 1 page, printed faoe
only.
Routing Original and four copies as follows: original and
first oopy to Division of Researoh, Statistics and Reoords,
Washington, D. C*j second copy to Regional Field Repre¬
sentative; third copy to State Youth Director; fourth oopy
retained by State Works Progress Administration.
Instructions for Preparation See Operating Procedure No. S-5.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix 6
WPA 154
WPA Form 1M
Page .
WORKS PROGRESS ADMINISTRATION
NUMBER OF PERSONS EMPLOYED ON WPA PROJECTS BY COUNTY
OF PROJECT OPERATION
State.
Week ending -
, 193..
ill
COOT(TT
(2)
Total—
(State-wide only)..
NUMBER OF PERSONS EMPLOYED
TOTAL
(3)
Total
W
Male
(5)
NONCEETITIED
Mala
(g)
WPA Form 164
BOMBER OF PERSONS EMPLOYED OH WPA PROJECTS
BY COONTY OF PROJECT OPERATION
Description Aotusl six* 8 by 15 lnohesj 1 page, faoe only.
Routing Srlginal and three oopiee &s followsi original and
Hrst eppy to Division of Researoh, Statlatioe and Records,
Washington, D. C.j second oopy to Regional Field Reprssen-
tativei third oopy retained by State Works Progress Admin¬
istration.
Instruotlons for Preparation See Operating Prooedure Ho. S-6.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
(Date submitted}
Prepared by.
Approved
Approved
State Statistician,
State Administrator,
Appendix B
WPA 155
WORKS PROGRESS ADMINISTRATION
MONTHLY REPORT OF EMPLOYMENT, HOURS WORKED, AND
EARNINGS ON NYA WORK PROJECTS
State .... Month .-. , 193.
Lor*
No.
(i)
ITIM
(S)
NOHBU or PltMNt
O)
HOUM WORKKD
(4)
ZABjnjcot
C6)
1
2
3
4
5
6
7
8
9
$
Prepared by .
Approved .
State Statistician
Approved .
Stale Administrator.
(Date mbmitud)
WPA Form 155
MONTHLY REPORT OF EMPLOYMENT, HOURS WORKED AND EARNINGS
ON NYA WORK PROJECTS
Description Actual sire 8 by 10J inches; 1 page, printed
faoe only.
Routing Original and four copies as follows? original and
first copy to Division of Research, Statistics and Reoords,
Washington, D. C.j seoand copy to Regional Field Repre¬
sentative; third copy to State Youth Director; fourth oopy
retained by State Works Progress Administration.
Instructions for Preparation See Operating Prooedure No. S-7.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C*
Appendix B
WPA 156
WPi Farm 1M
WORK* PROGRESS ADMINISTRATION
REPORT OF THE NUMBER OF PERSONS EMPLOYED ON WPA PROJECTS
BY TYPES OF PROJECTS
State
Operating Divi8tON_ . Week Ending. .... ■■■—. 193_
NUMBER OP PIMONI EMPLOYED
Llo*
No
<l)
TYPI OP PROJECT
(!)
Total
(3)
CiatlflKD
not CirariMJ
Total
w
M*N
<«)
Total
(7)
M«h
CB)
1
Highway, road, and atreet project*—Total
2
Secondary mail« and feeder*
S
Street* and alley*
4
Othor highway, road, and itreet project*
5
Public building projocta—Total
6
Educational building*
7
6
Othor building projocta
Recreational facilities, excluding building*—Total
0
Parka
10
11
Other reorcatlonal facility project*
Conservation projocta—Total
12
Flood control
13
Other conacrvatlon projocta
14
la
Publicly owned or operated utilities—Total
Sower avstoina
1
16
Other public utility project#
17
Transportation project#—Total
1
18
Airport# and airwaya
1
18
20
Other transportation project#
1 1
Education projocta—Total
21
Adult education
22
Nursery schools
1 !
23
Othor education project#
21
Professional and service projects—Total
2 i
UiUbUi, eil.iws, «r mSM tf pUk msri—TstaJ
2G
Finance records
27
Public safety
28
Public works
29
Welfare and relief
31
Extension of Government service#—Total
32
Public health and hospital work Total
tfPA Form 166
REPORT OF THE NTKBER OF PERSONS EMPLOYED
ON NPA PROJECTS BY TYPES OF PROJECTS
33
Dental clinics
34
Venereal disease clinics
33
Nursing -e
30
School health services
37
Other publio health projects
38
Library
Description Actual
lixe 10£ by 16£ inches; 1 page, face only,
three copies as follows t original and
38
Braille
Routing Original ant
40
Bookbinding and repair
iirst oopy to Division of Reaearoh, Statistics and Records,
Washington, D. C.j aooond copy to Regional Field Repre¬
sentative; third oopy retained by State Works Progress
41
Museum work
42
Other services
43
Studies and survey#—Total
Administration.
ee Operating Procedure No. S-9.
45
Engineering surveys
46
Legal studies and surveys
printea lorm supplied on request by works Progress Admin¬
istration, Washington, D. C.
47
Traffic surveys
48
Surveys of Government function*
48
General economic and social surveys
50
Other survev* and studio*
51
Archaeological projects
52
Other professional and service projects
53
Hoine economies projects—Total
54
School lunch projocta
55
Housekeeping aides
66
Household service demonstration centers
57
58
58
Other home economics projects
Recreation projects
Goods projects—Total
HO
Sewing
HI
Othor goods project#
- "
62
63
Sanitation and health projects
Distribution of surplus commodities
"
64
Projects not elsewhere classified
—
05
Grand Total
66
Memorandum (not included above)'
'
67
Federal Project No. 1—'Total
08
Art
09
Music
70
Theater
71
Writing
—■
72
i Historical records
Date submitted—
Prepared by_
Approved
Slate Statistician.
Approved
Stale Adminitlralar.
Appendix B
WPA 157
REPORT OF ENCUMBRANCES AND EXPENDITURES FOR WPA WORK 8.«r, _o» 8...T,
PROJECTS BY COUNTY AND BY SOURCES OF FUNDS
Cumulotlv Through
27_
28
30_
34_
35
WJ'A Form 157
REPORT Or ENCUVDRANCES AMD EXPENDITURES
FOB WPA WORK PROJECTS BY COUNTY AND
SOURCES OF FUNDS
Description Actual else 16 by 16 Inches) 1 page, prlotad
faoe only.
Routing Original and throo ooplee as rollomi original and
First oopy to Division of hoaaorch, Statlatlos and Uocorda,
flashington, D. C.i saoond oopy to Heglonnl Field Repre¬
sentatives third copy ratelnod by State Works Progress
Adalnlatretion■
Instruct lone for Preparation Soo Oporatlng Procedure No. S-10.
Printed forsi oupplied on raquoat by Works Progress Admin-
57212 O 38 2 titration, Washington, D. C.
Appendix B
WPA 201
W. p. a. Form 901
Boylnd July la, 19)7
Works Progress Administration
FIELD PRINTING CERTIFICATE
I Hereby Certify, as responsible officer in the field, that the printing and/or binding covered by
this voucher was, in my opinion, urgent or necessary to have done elsewhere than in the District of
Columbia for the exclusive use of a field office of this establishment, and that the same is of the class
and within the special authorization of the Joint Committee on Printing, dated July 13, 1937, quoted
below:
Congress of The United States
JOINT COMMITTEE ON PRINTING
washington
July 13, 1937.
Sir:
The Chairman has directed me to inform you that at a meeting of the
Joint Committee on Printing held on July 9th, last, requests for alloca¬
tions for field printing for the fiscal year ending June 30, 1938, were
considered, and that there was authorized for your branch of the service
an allotment as follows:
General $150,000
Attention is invited to pars. 70 to 83 of the Regulations of the Joint
Committee on Printing, which require that quarterly reports and samples of
field printing be submitted to the Committee.
The Comptroller General has been advised of this action on the part of
the Committee.
Very truly yours,
(Signed) Ansel Wold,
Clerk.
The Administrator,
Works Progress Administration,
Washington, D. C.
Purchase Order or Voucher Number - Amount, $_
Vendor
(Signed)
State Procurement Officer.
WPA Form 201
FIELD PRINTING CERTIFICATE
Desoriptlon Actual size 8 by 10| inches; 1 page, printed
face only.
Routing Prepared by State Procurement Offioe to accompany
vouchers for field printing.
Appendix B
WPA 251
Face and Reverse
W. p. A. »\>rm a«i
PERSONNEL APPLICATION
WORKS PROGRESS ADMINISTRATION OP .
This application is to be filled out In ink or typewriting
and signed by the applicant. If additional details will be of
valne, a separate sheet may be used and attached.
Leave this apace blank
I. Name ....... .......... .... A 8« J. Dale ..
(U.t num.) (First &im«) (Middle nam* J
4. Present address 5. Telephone number
(Sum* or R. f. D. and oily)
6. Legal address (l( different from above) ... .......... ...
7. Position desired ........ or .... ...............................
8. Salary desired, $ per month. 9. Lowost acceptable salary, f per month.
10. When could you begin wort II appointed? .... .......... ... ......
11. If appointed, would you be free to work ovortlmo when naccessary?
12. Would you accept temporary work? ..... a 13. If bo, for how long? -
14. Are you interested in part-time work? 15. If so, on what days of the week and during what hour* of the day?
16. Data and place of birth .. .......... 17. Are you a citizen?
18. If naturalized, give the time, date, and plaoe ... ...
19. State whether single, married, widowed, divorced, or separated .
20. State whether white, colored, or other race ....
21. State whether you live alone, with your husband, wife, children, or parents, or otherwise
22. Give the sex, age, and relationship of persons dependent upon you for support:
(а) Wholly dependent ... ... .....
(б) Partially dependent ... ...
23. Describe briefly the nature of any defects, infirmities, or chronic diseases you have ... ...
24. Have you ever 1
briefly:
iioen arrested, indicted, or convicted for violation of any law other tbi
nor traffic violation?
26. If you have had fewer than three omployors, give the following information as to three persons not related to you who can tell of your qualification:
Namt Addnsi Occupation
10—4130
WPA Form 251
PERSONNEL APPLICATION
Description Aotual sice 8 by loj inchesj 1 page, printed
face and reverse.
Routing Original and one copy as follows, original to
State Works Progress Administration; oopy retained by
local administrative office.
Instructions for Preparation See Handbook of Procedures,
chapter IV, eection 3.
Printed form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
TYPE OF SCIIOOL
NAME AND LOCATION
(City and State)
FROM —
(Ycnr)
'
DIPLOMA
(Yob or No)
KIND OK OOUltBK
1
I
1
a
Majors and minora
Other
2S. What parts of I ho above work were done in evening schools? ..
29. Give below an outline of your employment record, showing your present or List position first and working backward. List nil your prinolpal work, and in
addition even- full-time position you have held in the lost 3 years.
Month Year
NAME AND ADDRESS OF EMPLOYER
30. Outline any specialized experience which would bo of voluo In the work for which you ore applying .
31. I certify that the above statements aro true to the best of my knowledge and belief
Appendix' B
WPA 301
WPA Porm aoi P«g® 1 of 5 pagoe
Revised Sept. IBM)
WORKS PROGRESS ADMINISTRATION
PROJECT PROPOSAL
Amount requested, $ WPA Work Project No......... ... —
Amount approved, $ Serial No. Date
(Sponsor not to write above line)
Sponsor's proposal No Date of proposal
Last operated as - Project No. — —
(OWA, ERA, WPA) (If WPA, give 0. P. No.)
TO: Works Progress AnMiNiBTRATioN of
(Local) (District) (State)
1. Request is hereby made that the following proposal be reviewed and that a formal application be made for an allotment of
funds for this project under the rules and regulations of the Works Progress Administration.
(Sponsoring agency) (Official address—city, town, village) (County)
2. Location of project:
(City, town, village) (Oonnty)
Detailed location:
3. Description of project: -
4. Summary of estimated costs:
Item of cost
(1)
Federal funds
<2>
Sponsor's lands
(3)
Total
(4)
Amount
(dollari)
%
Amount
(dollar*)
%
Amount
(dollar*)
%
a. Labor:
1. Unskilled...
3. Skilled
4. Profesi
ional and technical
Subtotal (a)
Subtotal (a) plus (6)
c. Material, ec
1. Mater
uipment, and other costs:
Subtotal (c) only
Total cost of project
100
100
100
Total cost apportioned
%
%
100%
X X
FOR
1 STATE
™ OFFICE
16—saw
WPA Form 301
(Revised Sept. 1936)
PROJECT PROPOSAL
Description Actual sise 8 by lOg- inches; 5 pages, printed
face only.
Routing Original and two copies as follows: original to
State Works Progress Administration; first copy to local
administrative office; second oopy retained by sponsor.
Proposals for certain types of projects require an extra
copy of this form to be routed to Project Control Di¬
vision, Washington, D. C.
Instructions for Preparation See Handbook of Procedures,
" chapters VII and IX, and reverse of page 5 of form.
Printed form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
WPA Form 301—Continued.
(Revised Sept. IBM)
Pago 2 of 8 pagoo
5. Estimated man-months of work:
(а) Certified workers paid from Federal funds, man-months
(б) Total workers paid from Fedora) funds, man-months
(c) Total workers paid bv Sponsor, man-months
(rf) Total man-months, all workers
6. Estimated Federal expenditure per man-year of labor:
Total Federal cost of projoct (item 4, col. 2, total) _ .
Man-months labor (item 5 (6)) ™" T
7a. Preliminary plans and preparations will be complete -
• 7k. Final plans and specifications will bo complete -
8. (For statistical, survey, and research projects only). Complete specifications, copies of forms, schedules, instructions, tab¬
ulation plans, etc., are (are not)** submitted herewith.
0. Project can be started in days after notice to procood, and it is estimated that — working days
will be required for completion.
10. For the sponsor, project will be superintended by
(Nam.) (Title)
11. Maintenance and operation or publication of results of completed project will be provided as follows:
12. Project proposed has been approved by the following public planning or other agencies concerned:
13. Sponsor will (will not)** assume responsibility for results and will (will not)** assume responsibility for completion in the
event that funds allotted to project are inadequate.
14. Property on which project will be conducted is owned by
Sponsor has (has no)** jurisdiction to conduct project on this property.
Nora.—Projects may be conducted on public property of State, county, or local governments; on Federal property, with permission of proper Federal authority; or
on private property dedicated to the public use by easement. If project Is to be conducted on Federal property, there should be stated In this Item the name of
tbe Bureau or Department having Jurisdiction over the property.
15. The utility of this project will (will not) ** depend upon the completion of other public or private work. Explanation .
16. (For road construction projects only.) Project is (is not) on Federal Aid Highway.
Estimated Federal cost per mile: $ $ ■«- S —
(Bubgrade and drainage) (Surfacing) (Landscaping)
17. Justification (A short, concise statement giving reason or necessity for thfa proposed project, including any comments or
further statements about the nature of the work. Use additional sheet if necessary):
The ftalemtdts abort In which positive and negative alternatives are provided must be adjusted by the sponsor so that ona or the other only will apply.
wpa vorm 801—Continued. Pago 3 of 5 pagea
(Ilovlsod Rapt. IWO)
18. Labor Analysis: All labor should bo listed under appropriate classifications. Wage rates should agree with those determined
by the State Works Progress Administrator as applicable for locality. Consult WPA District Director for schedule.
Use separate lines for entries to differentiate sex, source, and Federal or Sponsor's funds. For columns 2, 4, and 0, use
subtotal lines for Federal labor only. Indicate female employees in column (1) thus: (F).
Occupational classification
Number of
i
Man-hours
Hours
per
month
Man-months
Rata
per
month
Dollars
Federal
Sponsor
Total
(»)
(2)
(3)
(4)
(0)
(6)
(7)
(8)
(9)
(»0)
X X
X X
1
X X
X X
X X
Skilled subtotal
X X
X X
—=
X X
Prof, and Tech. subtotaL
Labor subtotal
X X
X X
X X
X X
X X
X X
Superintend, subtotal...
X X
X X
X X
X X
X X
X X
Total.
* Denote thus: C, certified; N, non-certified; S, eponsor.
Page 4 of S pages
19.* Equipment analysis:
Kind of equipment (do
not Include small tool*
or sundrv equipment,
which will be includ¬
ed under item 21
•'Oilier direct costs"!
(t)
Capacity
(■>
Number of
units
(3)
lienlal
Doos
rale In¬
clude 0|V
WIIKOR?
(I'd or
nd)
(7)
Amount (dollars)
ltnto per
unit
(dollars)
(4)
Per hour,
(3)
l'orlod of rental
(hours, days,
weeks)
(0)
Kedaml funds
(8)
Sponsor's funds
(0)
Total
(10)
1
I
Total.
X X X X X
XXX
XXX
XXX
X X X X
XXX
L
20.* Materials and supplies analysis:
Description of materials
Amount (dollars)
Federal funds
Sponsor's funds
21.* Other direct costs, including a&fcty measures, transportation of workers, tools and sundry equipment (not included in
items 1R, 19, and 201.
Amount (dollars)
Total.
(4)
• Use separate lines to show It
is furnished by sponsor and those requested from Federal funds, Items 10, 20, and 21.
Page 5 of 8 pages
22. Estimate of coat by itema of work:
Quantity
(1)
Unit
(»)
Description of operation or feature of work (five break-down* by olaiaaa, aooordlnf
to nature of projeot)
(3)
Unit prloe
(4)
Amount (iollan)
(«)
Total cobt op
project
23. FISCAL CERTIFICATE:
This is to certify that the funds specified in this proposal, to be furnished by the sponsor (or equivalent value® in correspond¬
ing amounts), will be available for the prosecution of this project as needed.
Fiscal officer ..
24. SPONSORING CERTIFICATE:
The statements contained in this proposal have been checked by th% undersigned and are true to the best of his knowledge
and belief. It is agreed that the Works Progress Administration is under no obligation to complete the project proposed, if
approved and selected for operation (this sentence shall be deleted for Federal projects). This project will not cover work for
which funds at the disposition of the sponsor are currently appropriated, or work included in the normal governmental operations
of sponsoring agency; it will not result in the displacement of regular employees of this agency. The sponsoring agency is a public
body with legally vested authority to prosecute the type of work proposed. The work proposed will be done in full conformance
with all legal requirements. It is understood that Federal funds will be expended by the United States Treasury only upon pay
rolls and vouchers certified by the Works Progress Administration; and agreed that all operations will be in accordance with regu¬
lations prescribed under the Emergency Relief Appropriation Act of 1936 and orders and regulations issued thereunder. This
project is intended for the use or benefit of the public.
Sponsor's agent .
(Type or print name)
INSTRUCTIONS TO SPONSOR FOR PREPARING THE PROJECT PROPOSAL
The preparation of the project proposal and the furnishing of supplementary explanatory data are responsibilities of the spon¬
sor. Sponsors are advised to confer with local and district offices'of the Works Progress Administration to obtain information
with respect to occupational classifications, wage rates, working hours, and other matters of local application.
For construction type projects, the project proposal should be accompanied by plans or drawings and general specifications
or descriptions prepared in such a way as to permit intelligent review. Other supplementary data, to accompany the project
proposal, include a working procedure or discussion of the methods proposed for conducting the work and cost estimates,
suitably broken down by classes of work.
(OVER) 18—SM»
Pago 5 of 5 pages—Continued
Proposals for nonconstructlon typo projocta shall explain oxaotly what work is oontomplatod, why such work la needed,
hpw euch work la to bo proaooutod, and whom tho sponsor will uao to furnlah tho necessary supervision, olthor technical or"
administrative. The various forma to bo used shall bo submitted with tho projoot proposal for statistical, survoy, and research
projects; the forms to bo furnishod shall lnoludo coplos of sohodulos, tabulation plans, instructions, and any other spooial data
and statements which may bo required. Where standard working procedures havo been Issued by tho Works Progress
Administration, covering tho typo of work proposed, rcferonoo should bo mado to them by codo numbor on tho projcot proposal.
Most of the items in tho project proposal are self-explanatory. A few comments aro given bplow with respect to Borne items
which may require explanation.
Item No. 1.—The sponsoring agency must bo a public body with legal authority to carry out tho kind of work covered In tho
project proposal.
Item No. t.—On the line immediately following "Location of project" there should be indicated whether tho location is town-
wide, city-wide, township-wide, county-wide, district-wide, or State-wide. The detailed location may be given by streets and
boundaries, township, section and range, or definite relation by distances to well-oatabliahod landmarks, such as Federal Aid or
State Highways. Care should bo taken to prevent confusion with projects for which proposals may havo boon submitted previ¬
ously, whether approved or disapproved. For projects involving a number of locations, the following phrase should be added:
"Exclusive of other projects specifically approved."
/fern No. S.—A general description of the type of work should bo given first, using standard descriptions when applicable.
Immediately following, there should bo given a more amplified description, enumerating the nature and sizes of the elements of
the project.
Item No. 4-—This item shows a summary of the costs made up from the separate entries appearing on pages 3 and 4.
"Total cost apportioned" entries in columns (2) and (3) are determined by dividing the totals In columns (2) and (3), respec¬
tively, by the total in column (4).
Item No. 6.—The Federal cost per man-year of employment obtained by the solution of the fraction, derived as indicated,
gives a relative index of project desirability. Limiting man-year costs vary according to locality and type of work. Man-year
cost should not be lowered by the inclusion in the estimates of excessive amounts of labor beyond reasonable requirements for
performance of the work. It is permissible and entirely legitimate to lower the man-year cost from Federal funds by the spon¬
sor's furnishing material, equipment, and supervision instead of having these items secured through Federal expenditure.
Item No. 7b.—If definite dates cannot be given (ainoe it is not known whether or not the project will be approved and selected
for operation), it is necessary that sponsor indicate that detailed final plans and specifications will be furnished when needed
in the prosecution of the work. A statement to this effect should be made.
Item No. It.—This item should indicate whether approval has been obtained from local, State, and Federal agencies, other
than the sponsor, for projects over which such agencies may have partial jurisdiction. The approval of nonpublic agencies such
as chambers of commerce, boards of trade, etc., should not be stated under item 14, but may be indicated under item 17.
Item No. IB.—It is not desired to conduct a project when its usefulness will be contingent upon the completion of other work,
particularly where, in the latter case, completion is uncertain. A project to construct a building for which equipment is neces¬
sary but not provided would not be as desirable as one which provides useful facilities immediately upon completion.
Item No. 19.—Under column 1 it should be indicated whether the sponsor owns or proposes to rent the equipment which
is not to be secured from Federal funds. Columns (8) and (9) are derived as products of corresponding entries in columns (3),
(4), and (6).
Item No. tO.—Materials and supplies should be described in sufficient detail for accurate identification and the preparation
of requisitions. An additional sheet may be used when necessary. Prices should include delivery at the site of the project unless
actual delivery will be made by the use of equipment charged to the project and included in the project estimates. The use of
proprietary or noncompetitive materials is not restricted if such materials be furnished by the sponsor. If they be requested
from Federal funds, ample justification for their use will be necessary.
Item No. tl.—Besides tools and equipment, this item should include travel, rental of space required to conduct the project,
special architectural consulting or legal expense, met by the sponsor, and similar charges to the project which do not apply under
items 18, 19, and 20. The cost of land on which the project will be conducted must not be included as an element of the coat of
the work.
All projects should contemplate the use of safeguards and provide ample facilities for the safety and health of employees
and the general public. Scaffolding, machinery guards, etc., if needed, should be Included in the cost estimates. Other facilities
and supplies required, such as first aid kits, goggles, boots, and drinking-water containers, should also be included.
Item No. tt.—The data to be shown under this item provide a summary of the complete detailed estimates of total
costs of the project in which each distinct feature of the work is shown separately. Unit prices given are for materials in place,
irouting cost of labor of placing, material required, and equipment used for the purpose. Estimates should include sponsor's
as well as Federal funds. They should be comparable with current practice in public contract work or private enterprise, subject
only to such allowances as may be warranted by virtue of efficiency of available labor. The various features should be listed as
far as possible in the sequence In which the work will be performed. Dissimilar kinds of work should not be grouped into one item.
Separate entries may be made for certain types of operations which cover all features of the project as for example, supervision,
timekeeping, transportation of workers, and safety measures, when it is impracticable to combine such operations in the features
of work separately. If additional space is required, an extra sheet may be used for an extension.
The total cost of the project under this Item should agree with the total cost appearing under item 4; column 4.
Appendix B
WPA 303
fl
M
O z
< <
P
n
V) *
i I
I
I'jjil
ill
5®
in
!
i
HMHK
X X X X
X H M *
XX XX
XXX*
X X X *
XXX*
I
l m ;
I
X X X X
X X X X
x x x x
X X X X
S
?!
■: rf
!
I
If!
H!
!
£ 55 ■
ill"
I
Mi
§
I
i: i
:lv
i
WPA Form "303
WORK SCHEDULE AND ANALYSIS OF LABOR
Description Aotual size 16 by 14 lnoheaj 1 page, printed
faoe only.
Routing Original and two copies as followai original to
state offioej first oopy to distriot or other looal ad¬
ministrative offiooj seoond copy retained by sponsor.
Instructions for Preparation Sea Handbook of Procedures,
ohapter X, seotion 12.
Prlntod form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
Appendix B
WPA 306
Pace and Reverse
Works Progress Administration
PROJECT APPLICATION
O. P. No. .
ROB. NO. ..
District..
State
Amount requostod, $..
Amount, approved, $...
State Application No.
"(Duloj
(tUalo Administrator)
1. This project application is new □ Superseding Q.
2. If superseding, give:
(a) For superseded—Official Project No(s)
Pres. Letter No(s)
(6) For any supplements—Pres. Letter No(s). .
(c) Have obligations or encumbrances been set up against any of the superseded projects?..
(d) If so, give amount, $..
• Sponsorship
Is the superseded project now in operation?..
(Sponsor's official address)
4. Location of project: County .
Detailed location
.- City .
5. Description and character of work:
(Typo double-spaced; lor long description, type on oxtraaheet and attach.)
(a) If Federally owned, permission of
(Name of agoncy)
(5) If any part of project is on private property, proper
. owned property.
" State-owned^ etc.).
. been obtained.
(Uas or bos not)
.. have (have not) been
(Leases, easements, or rights-of-way)
obtained for all work on private property. If not, they will (will not) be obtained before any work is
started on the project.
If leased, give date lease e:mires
Leased to
(Month and year)
Is there any reversion clause in this lease?..
(Sponsor, State, etc.)
If there is, tho entire clause must appear in the
description or a copy of lease be attached.
(c) Will any Improvements be made to private property?..
(LEAVE BLANK)
TRANSCRI3KD
PBOOF It HAD
ACTION—.
DATE
INITIALS..
WPA Form 306
(Revised 10-1-36)
PROJECT APPLICATION
Description Aotual sise 8 by 10^ inches; 1 page, printed
face and reverse.
Routing Original and four copies as follows: original and
first and second copies to Project Control Division,
Washington, D.C.; third copy to State Works Progress Ad¬
ministration; fourth copy retained by initiating office.
Instructions for Preparation See Operating Procedure No. G-2.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
State State application No
7. Total man-years of work Total Federal man-years of work ......
8. Total man-hours of work Total Federal man-hours of work
9. Average number of workers per month:
(а) Persons certified as eligiblo for relief to bo paid from Federal funds
(б) Total persons paid from Federal funds: Male Femalo Total
(c) Total persons paid by sponsor
(d) Total number of workers [ (6) -f- (c)J.
10. (a) Ratio of average number of workers certified as eligible for roliof to all persons paid from Federal funds
[9(a) divided by 9(b) above]
(6) Percentage of total Federal funds required for payment of wages and salaries of all certified workers
percent.
11. Federal expenditure per man-year of labor (Federal funds total divided by Federal man-years) S
12. Project can be started days after notice of approval and will require months for completion.
13. If road work, give Federal cost per mile: — $ $ —
(Subgrade and drainage (Surfacing) (Landscaping)
14. Remarks:
15. Summary of estimated costs by source of
funds:
FrniRAL Funds
SroNion's Funds
Total
Dollars
Percent
Dollars
Percent
Dollars
Percent
1
1
Total Cost of Project. ..
100
100
100
Total Cost Apportioned
%
%
100%
XXX
16. (a) If this project is a continuation of work begun by some other agency, give amounts already spent on project, approximate dates
when work was done, source of funds, and agency in charge of work:
Frtnn— To— Agrncf in Charge Souret of Fundi Amount Expended
19 ,
(State, CWA, FEIt A, otc.) (Federal, State, etc.)
, 19
19..
(5) If this application is for the continuation of work undertaken under a project approved under the Emergency Relief Appropri¬
ation Act of 1935, give ~)..P, No. of previous project .
17. The proposed project complies with the requirements of the Works Progress Administration, and application for allocation of funds
is hereby made.
Checked: As to labor _
As to engineering .
Approved:
(Didtrid Director.)
INSTRUCTIONS
Z Project Control DivUlon will rescind superseded project when operation U started under ■unereedlng P">)ect.
4 Unow "Detailed location" give location within city, township, or oounty. Olve also project limits of roads, drainage works, river 1
5 aire a complete, specific description of the work contemplated. For road or street construction, sewers, waterlinea, etc., give ten
6 This item should be checked carefully, since It Is the basts of the eligibility of many projects.
7-1Z FUI In all blanks and have computations carefully checked
11 If accurate figures era not poeslble due to nature of project, give approslmate estimates. „ , .
14. Olye sny Information which will eirualn a hlgb man-yeai cost, a low percentage of persons certified1 aii eligible for relief, etc.
II Ffljin completely and check carefully^Use round dollars only-no rents should bo riven. Total Federal funds must be the*
16. Fill In to completely as poaslhls. Plana only one souroe of funds on a Una; I. use two lines where part of funds for a givtn peril
Appendix B
WFA 306A
Face and Reverse
Works Progress Administration
SUPPLEMENTARY PROJECT APPLICATION
Additional
.. amount requested, $ State Application No
Additional BuW- No -
State amount approved, $
O. P. No..
Reg. No. ..
District.
(Date)
(Slats Administrator)
1. An analysis has been made of the Supplementary Proposal submitted by:
(Sponsor's official addreaa)
2. Location of project: County
3. Approved Presidential Letter description:
Official Project No —
City.
Presidential Letter No. .
4. List here duplicate official project numbers which may have been assigned this project:
O. P. No. , P. L. No ; O. P. No , P. L. No...
5. Previous supplements to this project:
First supplement, P. L. No $
Second supplement, P. L. No. , S
6. The proposed project complies with the requirements of the Works Progress Administration, and application
for allocation of funds is hereby made.
7. It is hereby certified that not less than twenty-five per centum (25%) of the grant to be made in connection
with the foregoing project is to be expended for work under the project.
Checked: As to labor ..
(Signature)
(Date)
As to engineering .
As to —
(Signature)
(Signature)
(Date)
"(Date)""
Approved, .
(Date)
(District Director.)
ncm INSTRUCTIONS
2. Location shown should be that on approved Presidential Letter. II location stated in Presidential Letter is Incorrect, a soparnto request fur
change should be made to the Project Control Division.
The description must be ident
_. Where duplications of O. P. N ....... _. ...
8-12 These must bo carefully filled in to prevent delay in handling this supplementary application. Column (1) is to bo based on the projoct
as approved previous to this supplement.
13. Plaoe here any explanatory remarks which will assist In a clear understanding of breakdown.
14. Fill in completely. The omission of part of the breakdown means that the application will be hold up until the proper figures are obtained.
Check to see that the total Federal funds requested in this supplement agree with the amount approved on the reverse side over the Stalo
administrator's signature.
16. Explain reasons, giving any figures available, such as (a) approximate time lost during Inclement weather; (6) extent of any wage Increases since
"si of original application; (c) average dally employment on Job and any decrease or Increase expected with supplementary funds; (if)
ost of additional materials; (r) other reasons. Show, It possible, how much of supplementary funds
submittal of original application; (c) aver
underestimated cost of materials or cost c
would be expended for each of the above reasons.
(LEAVE BLANK)
Date Time
Paoor Read
Date Time
(over)
ACTION....
DATE
INITIALS..
WPA Form 306A
(Revised 10-1-36)
SUPPLEMENTARY PROJECT APPLICATION
Description Actual sise 8 by loj- inches; 1 page, printed
faoe and reverse.
Routing Original and four copies as follows: original and
first and second oopies to Projeot Control Division,
Washington, D. C.; third copy to State Works Progress
Administration; fourth copy retained by initiating office.
Instructions for Preparation See Operating Prooedure No. G-2.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
57212 0—38 3
Stat-© — Stato Application No Supp.
(1) Original plus pre¬
vious supplements
(8) This supplement
(8) Combined original
and all supplements, In¬
cluding this application
9. Average number of workers per month:
10. (a) Ratio of average number of workers oertified as eligible for relief to
(b) Percentage of total Federal funds required for payment of wages and
11. Federal expenditure per man-vear of labor
$
$
$
12. Original estimate of duration of project, months. Contemplated duration at present, months.
(As shown on original. Form 300) (Duration from start of work under this supplement)
13. Remarks - -
14. Summary 6f estimated costs:
(a) Original plus previous supplements:
(1) Fkdxkal Funds
(8) Sponsor's Funds
(3) Total
Dollars
Percent
Dollars
Percent
Dollars
Percent
Total Cost of Project.
100
100
100
Total Cost Apportioned.
%
%
100%
xxx
(b) This supplement:
Total Cost of Project
100
100
100
Total Cost Apportioned
%
%
100%
xxx
(c) Combined original and all supplements:
1
Total Cost of Project
100
100
100
Total Cost Apportioned..
%
%
100%
xxx
15. Reasons for supplemental request:
Appendix B
WPA 308
WPAVWmM
WORKS PROGRESS ADMINISTRATION
SPONSOR'S AGREEMENT
For Financing Non-Federal Projects
Emergency Relief Appropriation Act of 1937
iMWblMk
0. P. No
Pres. Letter No
MuMMIlbyBWuiw
State
County
Local Application No
State Application No.
Sponsor's Proposal No Date
To the Works Progress Administration:
In consideration of expenditures to be made: from Federal funds on the proposal designated above, we,
the sponsors, do hereby agree that we will finance such part of the entire cost thereof as is not to be supplied
from Federal funds.
Sponsor
By:
(N*n»—type or print)
(Title)
(Signature)
(Name—typ. or print)
(Title)
(Signet ore)
(Nemo—type cc print)
(Title)
ii—wiil. io—esao
(Signature)
WPA Form 308
SPONSOR'S AGREEMENT
Description Aotual sire 8 by 10& inchesj 1 page, printed
"" face only.
Routing Original and five copies as follows; original and
first and second copies to Project Control Division,
Washington, D.C.j third copy to State Works Progress
Administration; fourth copy to looal administrative office;
fifth copy retained by sponsor. "
Instructions for Preparation See Operating Procedure No. 0-2.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix 5
WPA 310
W. P. A. Form MO
(Date) 193
NOTICE OP WORKS PROGRESS ADMINISTRATION
PROJECT OPERATION
Work was started on the Works Progress Administration work project described below on
the date indicated.
(Signed) —
(Name) (Title)
DESCRIPTION
(Official project No.) (Work project No.) (Type of work symbol)
Work began on---------- - 193
The first pay roll period will end ----- 193
The pay roll period will be - - - Semimonthly □ Weekly □
Number of persons working, first pay roll period- - -
Estimated amount, first pay roll --------$
Total allotment for project - -
Allotment to be expended over a period of months.
WPA Form 310
NOTICE OF WORKS PROGRESS ADMINISTRATION
PROJECT OPERATION
Description Actual size 5g by 3^- inches; 1 page, printed
Taos only.
Routing Original and two copies as follows; original to
Treasury State Aooounts Office; first oopy to State
Works Progress Administration; second copy retained by
looal administrative office.
Instruotions for Preparation See Handbook of Procedures,
chapter XXII, section 6.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
Appendix B
WPA 330
Page 1 of 4 pages
WPA KOrm 090 1 •»' 4 P»I««
""*"""° WORKS PROGRESS ADMINISTRATION
WPA Sponsored Federal Project Number (. .)
Official Project Number ( )
REQUEST FOR APPROVAL OF PROJECT UNIT
Name of cooperating sponsor
Check type of cooperating sponsor:
Federal Statewide Local
Public Quasi-public Nonprofit private
Address of cooperating sponsor
Amount requested in section D below $ Date Form A-3C
Amount approved for duration of project unit... $ issuod
Amount allotted at this time to project unit S — Work Project No. ...
(Information above thle line filled in by State Administrator)
A.—Approval of Cooperating Sponsor
Fiscal Certificate of Representative of Cooperating Sponsor
(To be used when applicable)
This is to certify, that the cooperating sponsor's contributions specified, in this application will be
available for the prosecution of this project as needed.
Fiscal officer of agency representing—
Cooperating sponsor
Sponsoring Certificate
The statements contained in this application have been checked by the undersigned and are true to the
beet of his knowledge and belief. This project will not cover work for which local funds, public or private,
are currently available, or work generally included in the normal operations of the agency representing the
cooperating sponsor, nor will it result in the displacement of regular employees of this agency. It is also under¬
stood that Federal funds will be expended by the United States Treasury only upon pay rolls and vouchers
certified by the Works Progress Administration; and that all operations will be in accordance with regulations
prescribed under the Emergency Relief Appropriation Act of 1936 and administrative orders and instructions
issued by the Works Progress Administration.
Official representative
of cooperating sponsor
B.—Technical Approval
This project has been analyzed and it complies with the purpose and the regulations of the Federal
Project of which it iB to be a part.
n at rtOml Prefrct Director)
C.—Administrative Approval
This project unit has been analyzed and it complies financially and legally with the regulations under
which it is to be established.
D.—(All below thie line to be filled in by official representative of National Project Director)
(Bute) (County) (City) (Dou of nxjUMt)
1. Description of project and character of work:
2. Period of time for which funds ore requested ..
WPA Form 330
(Revised 7-20*36)
REQUEST FOR APPROVAL OF PROJECT UNIT
Description Aotual size 8 by 12& Inches; 4 pages, printed
face only.
Routing Original and five oopies as followa: original to
Division of Women1 a and Professional Projects, Washington,
D. C.j first oopy to Pedera.1 Direotor concernedj second
oopy to State Direotor, Women's and Professional Projeotsj
third oopy to offioi&l representative of Federal Projeot
Director; fourth oopy to oo-sponsorj fifth oopy to projeot
supervisor.
Instructions for Preparation See Operating Procedures Nos.
W-l and W-7.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Wl'A Form UO
lltaiM 1-*>-*)
S. Ia this a supplementary project? If so, give work project number of original.
Ptgs 1 of 4 psfos
ITEM or COST
(1)
Fadaral fundi
(1)
°-5ffaasr"
<■>
Total
(4)
Amount
*
Amount
*
Amount
*
a. Labor:
1. Unskilled
(Dalian)
(Dalian)
(Doflan)
3. Skilled
Subtotal (a)
b. superintendence:
Subtotal (a) plus (6)
e. Material, Equipment, and
Other Costs.
3. Other direct costa
Subtotal (c) only..
Total Cost op Project..
100
100
100
5. Eetimated man-months of work (base calculations on not more than 6 months):
a. Relief workers paid from Federal funds, man-n
b. Total workers paid from Federal funds, man-months
e. Total workers paid by cooperating sponsor, man-months
d. Total man-months all workers
6. Estimated Federal expenditure per man-year of labor:
Total Federal cost of project (item 4, col. 2, total) ^ ^
Man-months labor (item 5 (6))
7. What will be the nature of the cooperating sponsor's aid?
Supervisory Financial
Other
8. Is the proposed work to be executed on or for public property?
Explain .
9. Does this project involve: Travel?
How are these costs to be met? .
Rental of space?
10. Was this project operated under a previous program?
a. C. W. A. Project No.
b. E. R. A Project No
e. Other (tpecijy) .
What portion of work completed? ...
What portion of work completed? ...
11. Upon approval, how long before work can start?
12. What suggestions are offered for technical supervision?
13. Estimated elapsed time from beginning of proposed work to its completion months.
14. Will the funds requested on this proposal complete the work described for this project unit?
If not, what provisions could be made to carry it on without Federal funds?
Stiff®*
Pago 3 of 4 page*
16. Labor analysis:
All labor needed should be listed under appropriate classifications. Monthly earning rates—except
superintendence and labor furnished by cooperating sponsor—must agree with Executive Order dated
May 20, 1035, end revisions promulgated.
Men-month!
Professional and technical:
Superintendence:
Federal
Cooperating sponsor...
Totals
•Die letter "R" to Indicate worker! tek
Use letter "N" to Indicate nonrellef worker! peld from Pedwu fundi.
_ Deo letter "C" to Indicate work on p§"
TEtJKXJT
16. Major equipment
rental ana
jnua:
' "Page 4 «r 4 psfM
1
Numtar
JESS.
nlain.
eluihop-
1
g£&wK£ Ta -out
OTudIU
UDlf"
raft
Padantltand*
S'
"**• Total
o)
(S)
(3)
(«>
m
(«)
?»}
(■)
(•)
(10)
Total.
17. Materials and supplies analysis:
Unit pries
(S)
Amount (dollar*)
r*" I [I ITl"h|
cl)
(S)
(»)
(a)
Pad**! fund.
(S)
(T)
-Total
(8)
Total. _
18. OthAr direct costs, including tools, paraphernalia and sundry equipment (not included in items 15,16, and 17):
nuiptiob
Amount (doOan)
Fodenl funds
(3)
Coopntlnf
Mbrtjoo*
Total
(4)
::::::::::::::::
h
,
|
Total -
- '1
19. Condensed work schedule and number of man-months each month:
1
-At*
3
a
a
0
1
im una
Appendix B
WPA 350
WPA form 350
(revised 4/9/37)
WORKS PR0GRE88 AOM IN (8TRAT f.ON
SEMIMONTNbY INJURY SUMMARY
period from__ rid
DIRECT CAUSES
(0
number of
persons killed
number of 1
lost-time injuries
(number of
minor injuries
adminis¬
trative
(2)
project 1
(3) »
*admin|8-
7trative
(4)
project ,
(s) i
adminis¬
trative
(6)
project
(7)
rr. machinery
1
1
3.bexpl"0s ives
'
-J
•4. electricity,;fire
hot substances
.1
1
5. poisons, corrosive
substances
6. Falls of persons
7. Stepping, striking
against objects
8.ffalling objects
9. handling objects
I 10.-hand tools
1
1
i 1. animals
12. Miscellaneous
total (classes
1 to 12)
INOIRECT CAUSES, included under DIRECT CAUSES above
13. 1nfect1ons
14. flying objects
15. Eye injuries
total deaths
to date
(Signed)
total l'ostftlme
injuries todbaie
(title)
totalvm1 nor
i.CUMJF its "co lta te
WPA Form 350
(Revised 4-9-37)
SEMIMONTHLY INJURY SUMMARY
Description Actual size 8 by J.o£ inches; 1 page, faae
.only.
Routing Original and 31 .copy as ffollowst original to
Director of Safdty, Washington, D.C.; copy retained
by State Safety GConsultant.
Instruotions for ^Preparation See Operating IRrooadur©
—ib. ws.
Form to be duplicated by State Works Progress Admin¬
istration,
WPA Form 881—lUrlMd
FOREMAN'S ACCIDENT REPORT
This must be filled out to cover every accident regardless of whether
anyone was injured or not
A. M.
Date of accident Hour of day P• M.
Gty or town Dist. No.
Kind of project Proj. No —
Worker's name Age
Address —- -
Nature of his work
Nature of injury
Cause of accident
Was this accident preventable ? How ?
Worker given immediate first aid ? , Sent to doctor ?
Was he able to return to regular work on his next regular shift?
Signed
Prq/cd Foreman or SupcrtHoor.
NOTE.—Make report in duplicate.
Send original to Safety Representative, District office,
era Foreman to retain carbon copy in this book. 16—4600
WPA Form 351
(Revised)
FOREMAN'S ACCIDENT REPORT
Desoription Actual size 4 by 6 inches; 1 page, printed
face only.
Routing Original and 1 copy as follows! original to
Safety Inspector; copy retained on project*
Instructions for Preparation See Operating Procedure
Wo. 0-13.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
Appendix B
WPA 352
Paoe and Reverse
wpaForm851 WORKS PROGRESS ADMINISTRATION
(Revland 3-16-M)
SAFETY INSPECTION REPORT
PROJECT No
LOCATION DATE
TO TITLE
CONDITIONS FOUND .
RECOMMENDATIONS.
By
White Sheet to FOREMAN
Blue Sheet to STATE SAFETY CONSULTANT Title
Pink Sheet to LOCAL SUPERVISOR OF OPERATING DIVISION
Creen Sheet for INSPECTOR'S FILE Report No. -
Note: FOREMAN must deliver this copy promptly to the PROJECT ENGINEER (or SUPERVISOR)
(SEE RE VERSE SIDE)
WPA Form 352
(Revised 2-15-38)
SAFETY INSPECTION REPORT
Inscription Actual size 7-3/4 by 5-3/8 inches; 1 page,
printed faoe and reverse.
Routing Original and three copies as follows: original
to project foreman; firat oopy to State Safety Con¬
sultant; eecond oopy to local operating division;
third oopy retained by safety inspector•
Instructions for Preparation See Operating Prooedure No,
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
WORKS PROGRESS ADMINISTRATION
Date —
TO: Operating Division.
FROM: Project Engineer (or Supervisor), Project No.
SUBJECT: Safety recommendations.
The safety recommendations in this inspection report—
HAVE BEEN COMPLIED WITH AS OF THIS DATE.
HAVE NOT BEEN COMPLIED WITH FOR THE FOLLOWING REASONS:
Project Engineer (or Supervisor).
The above statement must be completed and this copy of the Safety Inspection Report forwarded to the District (or Local)
Office within 48 hours following receipt of recommendations. i«—em
Appendix B
WPA 353
wpa corm 353
WONKB PROGRESS ADMINISTRATION
monthly report of safety activities
Local Office
State
(a) safety personnel
number
State Safety Consultant
Ass't. State Safety Consultants
State Safety Representatives
Others (including office employees)
Total State Safety personnel
Distr ict
Oistrict Safety Inspectors
truck Inspectors
Project Safety Inspectors
others (including office employees)
Total District Safety Personnel ..
(b) inspect ion and tra ining
projects in Operation
Project inspections ..
Buildings Occupied ...
Camps Occupied
trucks in Use
Safety Meetings held .
first-Aid Classes ....
PROJECT LOCATIONS
Projects inspected
Buildings inspected
Camps Inspecteo
trucks inspected
Total Attendance at Safety Meetings .
number Enrolled in First-Aid Classes
Employees Certified after completing First-aid training
Recommendations in Safety Inspection Reports (WPA Form 352)
project proposals reviewed for Safety provisions
State and District Safety bulletins and posters issued (copies attached)
(c) remarks (use reverse sips if necessary)
(signed)_
(t.tle)_
WPA Form 353
MONTHLY REPORT OF SAFETY ACTIVITIES
Description Actual oiie 8 by lOj? inches; face only.
Routing Original and 1 copy as follows-, original to
Director of Safety, Washington, D.C.; copy retained
by State Safety Consultant. .
Instructions for Preparation See Operating Procedure
No. 0-13.
Form to be duplicated by State Works Progress Admin¬
istration.
57212 0-38 i
Appendix^ B,
WPA 355
Faoa and Reverse
WORKS PROGRESS ADMINISTRATION
SAFETY SECTION
CERTIFICATE OF APPROVAL
This certifies that the vehicle described herein has been inspected
bv a duly authorized inspector of this section and found to comply with
all safety regulations.
(Name of vehicle) (LIcense No.) (Date o? Inspection)
1
(Name of registered owner)
i
(Address of registered owner)
This vehicle is certified for use on work for the following purposes:
........ ... .. Capacity limit. ...
(Commercial delivery, etc.)
This certificate of approval expires , 193.—
STATE SAFETY CONSULTANT.
Countersigned at this
day of , 193.
By
Authorized Representative.
wfA Form 856 m—no7s
WPA Form 355
CERTIFICATION OF APPROVAL
Description Aotual size 4-3/4 by 4 inches; 1 page,
printed face and reverse.
Routing Two copies as follows: first oopy to be at-
taohed to vehiole; second oopy retained by Safety
Section.
Instructions for Preparation See WPA Safety Bulletin
—Wom
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
FOLLOW-UP INSPECTIONS
Date
BY
Date
BY
U.S. GOVERHEENT PRINTING OFFICE 16—6076
Appendix B
WPA 407.
REQUISITION FOR WORKERS
Requisition No *...
Date.
From...
(Operating agency)
At-
At.
To
Employment office) (Locality)
Please supply workers as indicated for project No Located in
(Olty, town, or village)
Description of project:
Occupation
Occupations) Title
Wage
Class
Num¬
ber
or
Work¬
ers "
53*2
Special Requirements or
Conditions
Date
to
Report
Hour
to
Report
Pi.ace to Report
The Foreman is:
1-
WPA DIVISION
OF
EMPLOYMENT
(Requisitioning officer)
WPA Form 401.
(Revised 8-13-36)
REQUEST FOR WORKERS
Deaoription Actual size 8 by 10^ inches; 1 page, printed
face only.
Routing Three copies as follows: copies 1 and 2 to Di-
vision of Employment; oopy 3 retained for files of
requisitioning officer.
Instructions for Preparation See Handbook of Procedures,
chapter XIV, seotion 3.
Printed form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
Appendix B
WPA 402
notice to report tor work on project
Name Identification No
Address Case No Date
Sex Race Certified □ Noncertified □
Transfer—Yes □ No □ From Project No to Project No
Additional information
You are asked to report ready for work at JD'AjM. □ P. M. on .
(Hoar)
at with
Wage class
Location of project.
(Exact plaoa to report)
(Title of oooapatlon)
(Day of week and date)
(Equipment owned)
(Projeot number)
(City or village. State; street number, building or other exact location)
Signature of placement officer
(Penalties are provided for illeghl signature, transfer, or nse of this form)
I hereby certify that I am the person named above as employee:
Employee's signature
Date employee begins work
Foreman's signature
U. S. GOVERNMENT PRINTING OFFICE
WPA- Form 402
(Revised 8vl5-36)
NOTICE TO REPORT FOR WORK ON PROJECT
Description Actual size 6 by 4 inches; 1 page, printed
face only.
Routing Five copies as follows: copy 1 to pay roll unit;
copies 2 and 4 to Division of Employment; copy 3 to
projeot; copy 5 to worker.
Instructions for Preparation See Handbook of Procedures,
chapter XIV, section 5.
Printed form supplied on request by Vforks Progress Ad¬
ministration, Washington, D. C.
Appendix B
WPA 403
Form 408 NOTICE OP TERMINATION OP EMPLOYMENT
Revised 8-iiwo
Name Identification No
Address - Case No. Date
Sex Race Certified □ Noncertified □
Now working as
(Title of occupation)
at -
(Location of project)
Effective □ A. M. □ P. M. on your
(Day of week and date)
employment will be terminated from Project No for the following reason:
(Signature of person issuing order)
Approved by Title
(Signature)
U. I. GOVERNMENT PRINTINO OfFICE 1*0 4101
WPA Form 403
(Revised 8-15-36)
NOTICE OF TERMINATION OF EMPLOYMENT
Description Aotual size 6 by 4 inches; 1 page, printed
face only.
Routing Five copies as follows; copy 1 to pay roll unit;
copies 2 and 4 to Division of Employment; oopy 3 to
project; copy 5 to worker.
Instructions for Preparation See Handbook of Procedures,
ohapter XIV, section 10.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
Appendix B
WPA 404
RECLASSIFICATION SLIP
Employee's name Identification No.
Address Case No - —
Date
Sex Race
Certified □ Noncertified □
Now working as Wage class —
(AaaJsned oooupation)
On Project No at _
(Address of project) (City or villugo)
A change in occupation is recommended for the above-named person:
To Wage class .
(Oooupation recommeudad)
Explanation:
By
(Foreman or supervisor)
Approved by
(Supervisor WPA Employment Division)
Effective with pay-roll period beginning , 193—
This form is to be used ONLY for changes in occupational title. It is not to be used for transfers or reassignment?
U.S. GOVERNMENT PRINTING OFFICE 10 4127
1
TO PAY ROLL UNIT
WPA Form 404
(Revised 8-15-36)
RECLASSIFICATION SLIP
Description Actual size 6 by 4 inches; 1 page, printed
face only.
Routing Five copies as follows: copy 1 to pay roll
unitj oopies 2 and 4 to Division of Employment; copy
3 to project; copy 5 to worker.
Instructions for Preparation See Handbook of Procedures,
chapter XIII, seotion 2.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
I?
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^ p ° T °
■flOtl 1 H-
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ooh-
8 £"£3 g
0.»0 O O M
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ftn cr
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tei?3
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I O
SgHOl
o !> o>
WORKS PROGRESS ADMINISTRATION
OCCUPATIONAL SCHEDULE OF HOURLY WAGE RATES, ASSIGNED
HOURS OF WORK PER MONTH, AND MONTHLY EARNINGS
Official Project
No
Effective date .
State
193....
Work Project
No
County.
The above spaces to be
used when schedule is pre¬
pared for one project only.
Give description of area here when more than one project is covered .
occupational Title
Maximum
Assigned
Hours or
Work per
Month
Occupational Title
Maximum
askoned
Hours op
Wore per
Month
The monthly earnings set forth in this schedule shall not exceed the maximum established in the Schedule of Monthly Earnings in Executive Order
No. 7040 and subsequent adjustments thereto.
The hourly wage rates shown above, having been determined to be not less than prevailing wage rates, were authorized by State Works Progress
Administrator's Order No. dated , 19
District Director.
I
a g
oi a
Appendix B
WPA 406
WPA FORM 406
WORKS PR0GRE88 ADMINISTRATION
REQUEST FOR EXEMPTION AUTHORIZATION
• assistant administrator State Request No._
division of Employment State
Works progress Administration Official Proj. No._
Washington, D. G. Date
... project description
b. Project location
C. Request is hereby made for exemption of the project as identified above from the following
provision (s) of aoministrative Order no. 54.
(!)□ Section 2. (2) □ Section 6, Item (c).
D. PRESENT EMPLOYMENT STATUS:
WAGE CLASS
NUMBER
PERSONS
TOTAL
PERCENT
NUMBER PERSONS
TOTAL
PERCENT
(7) TO (8)
CERTIF IED
NON-
CERTIFIED
SECURITY
NON-
SECUR ITY
(1)
(21
(3)
(4)
(51
(61
(71
(81
(91
UNSKILLEO
INTERMEDIATE
SKILLED
PROF. 4 TECH.
SUB-TOTAL
SUPERVISORY
GRAND TOTAL
e. authorization is requested for:
(1) Employment of not to exceed (NUMBER) MOn-certified persons (INCLUDING THE NUM¬
BER ALLowe0 WITHIN THE % LIMITATION) which number shall not exceed (PERCENT) of
the total persons engaged upon the project for the period from (date) to
(DATE).
(2) employment of not to exceed (number) persons (including the number alloweo
within the 5?6 limitation) at a monthly rate in excess of the established schedule of monthly
earnings which number shall not exceeo (percent) of the total persons engaged upon
the project for the per 100 from (date) to (date)
P. JUSTIFICATION OF REQUEST FOR AUTHORIZATION
RECOMMENOED 8Y: REQUESTED BY:
(STATE DIRECTOR OF EMPLOYMENT) (STATE ADMINISTRATOR)
WPA Form 406
REQUEST FOR EXEMPTION AUTHORIZATION
Description Actual size 8 by 10g inohesj 1 page, faoe
only.
Routing For exemptions subject to approval by State Ad-
~ ministrator, original and two copies as follows:
original and first copy to State Administrator; second
oopy retained by Division of Employment. For exemp¬
tions subject to approval by Assistant Administrator
in charge of Division of Employment, original
three copies as follows: original and first copy to
Assistant Administrator, Washington, D. C.; second oopy
to Regional Field Representative; third oopy retained
by Division of Employment.
Instructions for Preparation See Handbook of Procedures,
~ chapter XIV, seotion 13.
Form to be duplicated by State Works Progress Adminis¬
tration.
Appendix B
WPA 407
wpa form 407
WORKS PR0GRE88 ADMINISTRATION
EXEMPT ION AUTHORIZATION FROM CERTIFIED STATUS
to — State Administrator Authorization no.
works progress Administration State
c i ty > ~~
State . Official proj. no.
Under the authority granted in Administrative order no. 54 dated march 4, 1937, and with due
consideration of the request for exemption, state request no. , i hereby
grant the following exemption for the project identified above, from the requirements of section
6, Item (c) of Administrative Order no. 54:
to allow the employment of not to exceed non-certifi ed
(number)
persons, (including the number allowed within the % limitation) which number shall
not exceed of the total number of persons engaged upon the
project.
this authorization shall become effective , 193
and shall not extend beyond , 193 .
Any employment office designated by the United States Employment Service is
authorized to refer the number of persons covered by this exemption authorization from
non-certified- registrant? in accordance with assignment & referral procedures of the
works progress administration governing force account projects.
assistant administrator
WPA Form 407
EXEMPTION AUTHORIZATION FROM CERTIFIED STATUS
Deaorlption Actual size 8 by lojjf inohes; 1 page, faoe only,
Routing fror exemptions authorized by State Administrator,
original and two copies as follows: original to Division
of Employment| first copy to Division of Financej third
oopy retained by State Administrator. For exemptions
authorized by Assistant Administrator in charge of Di¬
vision of Employment, Washington, D, C., original and
two oopies aa follows: original and first copy to State
Administrator; second oopy retained by Assistant Admin¬
istrator .
Instruotions for Preparation See Handbook of Procedures,
ohapter XIV, section" 13.
Form to be duplicated by State Works Progress Adminis¬
tration.
57212 0—38 5
Appendix B
WPA 408
wpa Form 408
WORKS PROGRESS ADMINISTRATION
EXEMPTION AUTHORIZATION FROM SCHEDULE OF MONTHLY EARNINGS
TO — STATE ADMINISTRATOR AUTHORIZATION N0._
works Progress Administration State
City Official Proj. No.
S ta te .
Under the Authority granteo in Administrative Oroer No. 54 oateo March 4, 1937, and with oue
consideration of the request for exemption, state request no. , i hereby
grant the following exemption fcr the project identified above, from the requirements of sec¬
tion 2 of Aoministrative Order no. 54:
to allow the employment of not to exceed persons at a
(number)
monthly wage (or earning) not in accordance with the provisions governing pay¬
ment of persons established by tl-e schedule of monthly earnings, which number
of persons (incluoinc the number allowed within the 5$ limitation) shall not
exceeo of the total number of persons engaged upon the project.
(percent)
This authorization shall become effective ,
193 , ano shall not extend beyond ,193 .
Assistant Administrator
WPA Form 408
EXEMPTION AUTHORIZATIONS FROM SCHEDULE
OF MONTHLY EARNINGS
Description Actual size 8 by 10§- inches; 1 page, face
only.
Routing For exemptions authorized by State Administrator,
original and tro copies ae follows* original to Di¬
vision of Employment; first oopy to Division of Fi¬
nance; third oopy retained by State Administrator. For
exemptions authorized by Assistant Administrator in
charge of Division of Employment, Washington, D.C.,
original and two copies as follows: original and first
oopy to State Administrator; second copy retained by
Assistant Administrator.
Instructions for Preparation See Handbook of Procedures,
chapter" ilV, section 15.
Form to be duplicated by State Works Progress Adminis¬
tration.
Appendix B
WPA 412
* Worker's Identification Card
1
(Date issued)
O (Nimo of worker) (Identification No.)
2
n
C
a
(Address)
v (Height) (Weight)
(Sex) (Color eyes) (Age) (Color hair)
CLASSIFICATION
(Primary)
(Issuing officer)
(Secondary)
(Title—'Diyiaion of employment)
WJfc*A 1'onn 41a ore 10—6830
WPA Form 412
WORKER'S IDENTIFICATION CARD
Description Actual size 4-|r by 2^ inches; card, printed face
only.
Routing Original only, to project worker.
Instructions for Preparation See Operating Procedure No. E—3.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C,
Appendix B
WPA 502
TIME REPORT
FOR PERSONAL SERVICES—WORK PROJECTS
HOURLY iAtlt
| CHICK QUI OB BOTH i CerlUad ae Kllilble CI NeeawtUad a|
Pey RoU No
Page No
Official Project No._
Work Projoct No
Type of Work 8ymbol
Cite State Administrator's order
fixing rates of pay.
Period from to inclusive. No Date
nr
&
V
—.
■a?
trs-
"I"
IS)
KBUV.-,»r.U,Ubl«,
EijL
U«)
(IS)
fl4)
iS*l£f
■ass?
tfr
(4)
T
is)
•£23*
(S)
—
30
31
22
22
23
23
34
34
25
25
20
28
27
27
28
23
»
20
10
30
31
31
33
12
"
33
34
34
35
35
Total, ros ma taoe,
I hanbr aanllr u»l lk« pa
P —PiofialouL
m raaaliad krUaut rankto
WPA Pom 602
(Revised 6-10-37)
TIMS REPORT
POl FERSOHAL SERVICES-WORK PROJECTS HOURLY BASIS
Description Actual alto 14 by 17 inchesj 1 page, printed
face only.
Routing Original and one oopy as followsi original to
pay roll unltj oopy retained by timekeeper.
tMtTOtlsM for Preparation See Operating Prooedure lo.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
Appendix B
WPA 503
Face &nd Reverse
Vouonsn No.
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECTS
HOURLY BASIS
Pay Roll No
D. O. Symbol No. .
Agency WORKS PROGRESS ADMIN jSTRATjON
Period from ...
Appropriation .
, inclusive.
(Official project numtwi
(Appropriation nymbol)
For services rendered during the period specified above as stated in "Amount Paid" column
amount
Notation*
$
Account verified; correct for -
(Signature or InlUili)
$
•i certify that the within pay roll, in pages, is correct; that it appears from the records of my office that the persons named thereon were
legally appointed or employed and each has performed the services reauired by law and regulation during the period mentioned; that all the conditions of
employment as presented \>y Executive Orders and Regulations have been complied with; that such services have been performed under my supervision;
that no person whose name appears on the within pay roll is paid for any period of absence in excess of that allowed by law; and that the total amount
of this roll is chargeable to the appropriation as indicated above.
Approved for $.
Total pat boll.
Appendix B
WPA 503a
Pace and Reverse
W. P. A. FOr
rannii
■HMmtaraiW
PAT ROLL FOR PERSONAL SERVICES-WORK PROJECTS
HOURLY BASIS
| °g|CBKOT0HKE Cartlflcd u EUgtbla | [ Nonoortlflad U\
Pay Roll No..
Page No
wokk« wwoqwms apmihiitkation
Project
Official Project No.
Work Project No
Type of Work Symbol.
Sponsored by
Disbursing officer _
(Nam* at pobUa body ud <v
Cite State Administrator's Order (s) Fixing
Hourly Rate(»)
, inclusive.
Haha or lunorma
WPA Form 503a
(Revised 8-5-36)
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECT
HOURLY BASIS
(Memorandum)
Description Actual site 11 by 17 inches; .1 page, printed face
and reverse.
Pouting Three copies, to be prepared together with WPA Form 503
Revised, as follows: first and second oopiea to Treasury
State Accounts Office; third copy retained by Division of
Finance.
Instructions for Preparation See Operating Procedure No. F-5.
Printed form supplied an request by Works Progress Adminis¬
tration, Washington, D. C.
Totals for this i
Appendix B
WPA 603b
Appendix B
WPA 503o
W. P. A. form SOeo-n.rlnd
xw
CONTINUATION SHUT
PAY ROLL FOR PERSONAL SERVICES — WORK PROJECTS
HOURLY BASIS
Pay Roll No._
Page No
Certified m Eligible [ | Noneertlfled | | |
Agency-
Project
Sponsored by _
WORKS PROGRESS ADMINISTRATION
Official Project No
Work Project No
Type of Work Symbol—
of publlo body ud department)
Period from _
Cite State Administrator's Order(s) Firing
Hourly Rate(s)
_, inclusive.
Bktlotxo as
U affecting pa J mini m
be ebown bera
WPA Form 503c
(Revised 9-5-36)
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECT
HOURLY BASIS
(Memorandum Continuation Sheet)
Description Aotual size 11 by 17 inches; 1 page, printed face
only.
Routing Three copies, to be prepared together with WPA Form
503b Revised, as follows: first and second copies to Treasury
State Accounts Office; third copy retained by Division of
Finanoe.
Instructions for Preparation See Operating Procedure No. F-5.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Totals for this page,
Appendix B
WPA 504
Face and Reverse
57212 0-38-
PAY ROLL FOR PERSONAL SERVICES—WORK PROJECTS
HOURLY BASIS FOR WORK CAMPS
Vouchor No.
Pay Roll No
D. O. Symbol No.
Awnry WORKS PROGRESS ADMINISTRATION
Period from .
Appropriatiot
tOOrUI Irjm No l
iTjrj* oi art** symbol*
(Location ■ JlubolI
For sendees rendered during the period specified above as stated in "Amount paid" column
Auorxt
Notations
s.
Differences
OUmuturr or Initials)
* I cer~itt that the within pay roll, in pages, is correct; tlint it appears from the records of my office that the persons named thereon were
legally appointed or employed, and each has performed the sen-ices required by law and regulation during the period montioned; that all the conditions of
employment as proscribed by Executive orders and regulations have been complied with; that such son-ices have been performed under my supen-ision; that
no person whose name appears on the within pay roll is paid for any period of absence in excess of that allowed by law; and that tho total amount of t!
roll is chargeable to the appropriation as indicated above.
'Approved for, $_
• Ttu» certificate mast be made by the certifying officer designated by the agency named,
signature only it Decenary; otherwise the approving officer will sign in the blank
PROJECT. USE SPACE BELOW FOR DISTRIBUTION TO VARIOUS PROJECTS
trar or
Symbol
Dmimoa and Location or I'sojcct
Ilovu
in Pat
Status .
1
Total pat hull matrinuted,
Appendix B
WPA 504a
Face and Reverse
ComnlrulUi Ucnaral V. 8.
Novtinbn 14, 1M4
MEMORANDUM
PAY ROLL FOR PERSONAL SERVICES—WORK PROJECTS
HOURLY BASIS FOR WORK CAMPS
} CuimriEO Ait Bmoibw Q Nonckiitikied [~1
(List certified and noncertlfied peraon* in two group* under Mparata heading*)
Agency WORKS PROGRESS ADMINISTRATION
° fALnfcl mlltrtrt) nV.inl.vl
Pay Roll No
Pago No
Official Project No._
Work Project No
Projoct
Sponsored by _
Disbursing officer _
(Namo ot public body nod dopnrtniflnt)
Period from _
Type of Work Symbol
Cite State Administrator's Order(s)
Fixing Hourly Rutc(s)
Fixing Subsistence Rate(s)
, inclusive.
Nam* or EurLorr*
iDrcrnncinoN
WPA Form 504a
(Revised 11-16-36)
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECT
HO'JRLY BASIS FOR WORK CAMPS
(Memorendum)
Description Actual size 11 by 17 inches; 1 page, printed face
and reverse.
Routing Three copies, to be prepared together with WPA Form
504 Revised, as follows: first and second copies to Treas¬
ury State Accounty Office; third copy retained by Division
of Finance.
Instructions for Preparation See Operating Procedure No. F-8.
Printed form supplied on request by Works Progross Adminis¬
tration, Washington, D. C.
Totals for this page,
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECTS
HOURLY BASIS FOR WORK CAMPS
Vouohor No
Pay Iloll No
D. O. Symbol No.
Agoncv WORKS PROGRESS ADMINISTRATION
_, inclusive.
Appropriation _
PAID BY
Fob Uai or Putnm Orriri*
(TV ark No.) |
(Appropriation «ymbol)
For services rendered during the period specifiod above ns stated in "Amount paid" column
$
NOTATIO*.
1
(Sicuture at Initials)
MEMORANDUI
WHEN PAY ROLL COVERS MORE THAN ONE PROJECT, USE SPACE BELOW FOR DISTRIBUTION TO VARIOUS PROJECTS
omnai pbojcct
SVUMOL
wo5"c ssr
Trra o»
WOM
Dmurno* in Location or Patum
a°Ptr
SiiToa
Total pay roll distributed,
Appendix B
WPA 506
Face and Reverse
PAT ROLL FOR PERSONAL SERVICES AND OWNER-OPERATED Voucher N°
EQUIPMENT—WORK PROJECTS r.yRoUNo.
(Tumi, Truck*, Etc.)
Relief Appropriation Act of 1935, Public No. 11—74th Congress
D. O. Symbol No..
Agency WORKS PROGRESS ADMINISTRATION
Appropriation:
Fob Usb or T«r.iamT Diubtmxt:
-I—
(Trv 0' rw* iJTObol)
-i"
i A ptropratioc gyznboD
For services rendered during the period specified abpve as stated in "Amount Paid "
Account verified; correct for
'anwOT uf iLUtak)
* I cebtipt that the within pay roll, in _
pages, is correct; that it appears from the records of my office that
the persons named thereon were legally appointed or employed, and each has performed the services required by law and
regulation during the period mentioned; that all the conditions of employment as proscribed by Executive orders and
regulations have been complied with; that such services have been performed under'my supervision; that no porson whoso
name appears on the within pay roll is paid for any period of absence in excess of that allowed by law; and that the
total amount of this roll is chargeable to the appropriation as indicated above.
* Approved for $_
(■ion \
ORIGINAL. )
ONLY /
• This certificate must be made by the certifying officer designated by the agency named. If the ability to certify, and authority to
approve, arc combined in ono person, one signature only in necessary; otherwise tho approving officer will sign In the blank spaoe "Approved
for $ " and over his official title. .. ...
Appendix B
WPA 506a
Pace and Reverse
PAT ROLL FOR PERSONAL SERVICES AND OWNER-OPERATED
EQUIPMENT—WORK PROJECTS Pay Roll No
Teema, Track*, Etc.)
j Relief Appropriation Act of 1935, Public No. 11—74th CongUM
- D. O. Symbol No...
Agency WORKS PROGRESS ADMINISTRATION
Appropriation: _
Poa Use or Tuastot Dbpabtxixt:
N«(work symbol) I (La
For services rendered during the period specified above as stated in "Amount Paid "
AMOUNT
NOTATIONS
Account verified; correct for .. „ —
ISKsaiura or Initials)
Appendix 8
WPA 506b
■W.v. A. Form No. «»•-!
oJSSaffSSSLft.a
Agency._
Project
Sponsored by_
Disbursing officer.
CONTINUATION SHEET
PAY ROLL FOR PERSONAL SERVICES AND OWNER-OPERATED
EQUIPMENT-WORK PROJECTS
(Turns, Trucks, etc.)
Emergency Relief Appropriation Act of 1938, Public No. 11—74th Confrere
WORKS PROGRESS ADMINISTRATION
Pay Roll No.
Pago No
Official Project No. ..
Work Project No
Type of Work Symbol
(Nun* of public body end department)
, inclusive.
WPA Form 506b
PAY ROLL FOR PERSONAL SERVICES
AND OWNER-OPERATED EQUIFMENT-WORK PROJECTS
TEAMS, TRUCKS, ETC.
(Continuation Sheet)
Description Actual site 11 by 17 inches] 1 page, printed faoe
and reverse same.
Pouting Original only (to be prepared when necessary to accompany
WPA Form 506), to Treasury State Acoounts Office.
Instructions for Preparation See Operating Procedure No. F-8.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Totals for thib page,
Appendix B
WPA 506c
Appendix B
WPA 507
WORKS PROGRESS ADMINISTRATION-INDIVIDUAL EARNINGS RECORD
NAME IDENTIFICATION NO
ADDRESS— INITIAL ASSIGNMENT-DATE
PAY PERIOD
ENDING
(1)
PROJECT
NUMBER
(2)
OCCUPATION
(3)
CLASS
U)
HOURS
LOST
NOT
ALLOW¬
ABLE
<B)
TOTAL
HOURS
WORKED
(B)
RATE
PER
HOUR
<7}
AMOUNT
PAID
(B)
ALLOW¬
ABLE
HOURS
CARRIED
OVER
(0)
REMARKS
do)
U. OOVUNHCNT PIINTINQ orpicc IS—4164
WPA Form 507
(Revised 7-1-36)
INDIVIDUAL EARNINGS RECORD
Deaorlptlon Aotual size 8 by 5 inches; oard, printed
face and reverse same.
Routing Original only, maintained by Division of Finance.
Instructions for Preparation See Operating Prooedure
No. F-13.
Printed form supplied on request by Works Progress
Administration, Washington, D.C.
Appendix B
WPA 507a
WPl Fonn sot a works progress administration
INDIVIDUAL EARNINGS RECORD—SUPERVISORY PROJECT EMPLOYEES
Name Identification No
Address - Initial assignment date
Pat
Period
Ending
<1>
Project
No.
(2)
Occupation
(3)
Monthly
Assigned
Hours
(4)
Monthly
Salary
(«)
Assioned
Hours for
Pay Period
(0)
Rate for
Pay Period
(7)
Total
Hours
Woreed
<H>
Hours in
Non-fat
Status
(9)
Deduction
for Non-
pay Status
(10)
Amount Paid
(11)
-
—
o. a ootim.btt raimwo omci Id—0581
WPA Form 507a
INDIVIDUAL EARNINGS RECORD-SUPERVISORY PROJECT EMPLOYEES
Description Actual size 8 by 5 inches; card, printed face and
reverse same.
Routing Original only, maintained by Division of Finance,
Instructions for Preparation See Operating Procedure No. F-13.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
WPA 507b
WPA Form 507 b
WORKS PROGRESS ADMINISTRATION
INDIVIDUAL EARNINGS RECORD—APPOINTIVE EMPLOYEES
General Administrative Expense
General Project Supervisory Expense .
Sex
Marital status .
Appointed ..
E. O. D. ...
Pat Roll
Period Ending
(1)
Annual Lxavb
Sick Lkave
Gross
Amount
Earned
(8)
Deduc¬
tions
(9)
Net
Amount
Paid
(10)
Remarks
(11)
Accumu¬
lated
(2)
Granted
(3)
Balance
(4)
Accumu¬
lated
<«)
Granted
(6)
Balance
(7)
lft—0683
WPA Form 507b
INDIVIDUAL EARNINGS RECORD-APPOINTIVE EMPLOTEES
Description Aotusl size 8 by 5 inches; card, printed face and
reverse same.
Routing Original only, maintained by Division of Finanoe.
Instructions for Preparation See Operating Prooedure No. F-I3.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
57212 0—38 7
Appendix B
WPA 508
IT. □<
_o_
i
J
—
I
!'
i
Total
H
iF
an
i
J
(s>
u..t,
<t>
1
2
3
4
6
6
7
8
0
10
-
10
11
11
12
13
14
15
16
17
IS
-
Afttioveo a. 1. Acotsacy . .
Totals Kob Tu.s Pact,
KPA Fora 500
(Reviled 10-15-37)
AND RECORD OF EQUIPMENT RENTAL SERVICES
£«orl|tlon^Aotual ■Ice 14 by 17 imohesj 1 pago, printed
Routing Original and 1 oopy as followsi original to Dl-
vlsion of Finanoej oopy retained by projoot timekeopor.
Instructions for Preparation See Operating Prooedure No. P-8.
Printed form eupplled on request by Worlcs Progress
'Administration, Washington, D.C.
Appendix B
WPA 509
Face and Reverse
Form approved by
Comptroller General, u. 8.
December 3. IMS
PAT ROLL FOR PERSONAL SERVICES—WORK PROJECTS*
Supervisory (or Administrative) Employees on Semimonthly Basis Chargeable to Work Projects
Emergency Relief Appropriation Act of 1936, Public No. 11, 74th Congreee
Pat Roii. No..
Page No.
Official Project
Work Project
No
Ttpb of Work
Agency .. ON..
(Name sad designation of disbursing officer)
Period from .
, 193..., to 193...
DEDUCTIONS
REMARKS
Una
No.
Nam. of employee, Identification nun
occupation
nber, and
Rata far parlod
Oross
amount
earned
Retire¬
ment
Other
Net amount
paid
Check number
and date drawn an
Treasurer of U. S.
F. R. B.
£3
si
Other deduct!ana to be
clearly and fully ex¬
plained, together with
■uch (acta as may affect
pay flatus
(1)
(S)
(3)
(4)
<«)
(«)
(7)
W
(9)
(10)
1
2
3
WPA Form 509
(Revised 12-3-35)
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECTS
SUPERVISORY (OR ADMINISTRATIVE) EMPLOYEES ON SEMIMONTHLY
BASIS CHARGEABLE TO WORK PROJECTS
Description Actual size 8g by 11 inchesj 1 page, printed faoe and
reverse.
Routing Original only, to Treasury State Accounts Office.
Instructions for Preparation See Operating Procedure No. F-6.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C#
•Note.—To be uaed only for work project supervisory or administrative employees receiving nonsecurity wages.
PAY ROLL FOR PERSONAL SERVICES—WORK PROJECTS
Supervisory (or Administrative) Employees on Semimonthly Basis Chargeable to Woi4c fYoJwcta
Emergency Relief Appropriation Act of 1935, Public No. 11, 74th CongreM
Agency WO^ PROG^SS ADMINISTRATION
VoUfJHBR No
1*at Roll No
D. O. Symbol No. .
Project
Sponsored by ..
Period from ....
Appropriation .
(Din ti let)
(Description and location)
(Nameof public body and department)
to
, inclusive.
For Use of Treasury Department:
(Officii! project no.)
(Type of work symbol)
(Location symbol)
(Par line of Paying Officer)
(Project authorixation no.) 1
(Appropriation symbol) |
(Sublimits Uon)
DISTRIBUTE pay rail by projects if services performed apply to more than one project. Use gross amount to bo charged to allotted funds
OFFICIAL
PROJECT
NO.
WORK
PROJECT
NO.
Symbol
AMOUNT
Hours
In Pay
Status
OFFICIAL
PROJECT
NO.
WORK
PROJECT
NO.
Tyne
of Work
Symbol
AMOUNT
Hours
In Pay
Status
i
!
TOTAL.—Net amount paid plus deductions charge¬
able to project fundi
For services rendered during the period specified above as stated in "Gross amount
earned" column.
AMOUNT
$
NOTATIONS
(Signature or Initials)
I certify that the within pay roll, in pages, is correct; that it appears from .the records of my office that the
persons named thereon were legally appointed or employed, and each has performed the services required by law and
regulation during the period mentioned; that all the conditions of employment as prescribed by Executive orders and
regulations have been complied with; that such services, except as otherwise indicated in the column of "Remarks",
have been performed under my supervision; that no person whose name appears on the within pay roll is paid for any
period of absence in excess of that allowed by law; that deductions have been made from the compensation of all em¬
ployees against whom charges have accrued during the period of the pay roll; that the reasonable value of allowance?
furnished in kind is stated in every case; and that the total amount of this roll is chargeable to the appropriationn?
indicated above.
* Approved for
(sign \
ORIGINAL 1
ONLY /
* This certificate must be made by the certifying officer designated by the agency named. If the ability to certify, and authority to
approve, are combined in I person, 1 signature only is necessary; otherwise the approving officer will sign in the blank space "Approved
for $ " and over his official title. s.«.sowmm«w io-<ws
Appendix B
WPA 509a
Face and Reverse
W. p. a. Form soon Pay Roll No.
Form approved by
Comptroller Ooneral, U. 8.
December S, IBM
Paob No
Official Project
PAY ROLL FOR PERSONAL SERVICES—WORK PROJECTS* N<,
Work Project
Supervisory (or Administrative) Employees on Semimonthly Basis Chargeable to Work Projects
No.
Emergency Relief Appropriation Act of 193S, Public No. 11, 74th Congrete Type of Work
Symbol
Agoncy WORKS PROGRESS ADMINISTRATION
C (State) (District) (County)
Period from , 193..., to , 193—
(Namo and designation of disbursing officer)
Lino
No.
<»)
Nunc of employee, identification number, and
occupation
(t)
Rate tor period
(S)
Gross
amount
(4)
DEDUCTIONS
Not ^amount
(V
Check number
and date drawn on
Treasurer of U. S.
r. r. b.
(8)
REMARKS
Retire-
<«>
Other
<6)
£3
if
H
(9)
Other deductions to be
clearly and fully ex¬
plained, together with
such (acts as may affect
pay status
(10)
1
2
3
4
5
6
7
8
9
10
>1
12
13
14
16
16
17
18
•Note.—To be used only for work project supervisory or administrative employees receiving nonsecurity wages.
WPA Form 509a
(Revised 12-3-35)
PAY ROLL FOR PERSONAL SERVICES-WORK PROJECTS
SUPERVISORY (OR ADMINISTRATIVE) EMPLOYEES ON SEMIMONTHLY
BASIS CHARGEABLE TO WORK PROJECTS
(Memorandum)
Description Aotual site 8-| by 11 inches; 1 page, printed face and
reverse.
Routing Three copies, to be prepared together with WPA Form 509
Revised, as follows: first and second oopies to Treasury State
Accounts Office; third copy retained by Division of Finance.
Instructions for Preparation See Operating Procedure No. F-6.
Printed form supplied on request by Works Progress Administra¬
tion, Washington, D. C.
PAY ROLL FOR PERSONAL SERVICES—WORK PROJECTS
Supervisory (or Administrative) Employees on Semimonthly Basis Chargeable to Work Projects VocoHBB No. —.~
Emergency Relief Appropriation Act of 19SS, Public No. 11, 74th Conyreee
Agency. WORKS PROGRESS ADMINISTRATION
Pat Roll No. ..
D. O. Stmdol No.
Project
Sponsored by .
Period from
Appropriation .
(Description and location)
(Noma of public body and dspsrtmsnt)
to , inclusive.
For Use or Treasury Department:
(Work project noO
(Type of work symbol)
(Location symbol)
(Tor Use of Paying Officer)
DISTRIBUTE pay rail by projects If sorrtcas pi
s than one project.
ml to be charged to allotted funds
OFFICIAL
PROTECT
NO.
WOBK
PROTECT
NO.
oT&crk
Symbol
AMOUNT
In Pay
Status
OFFICIAL
PROTECT
NO.
WORE
PROTECT
NO.
JVS.
Symbol
AMOUNT
Boars
in Pay
Status
TOTAL.—Net amount paid plus deductions charge¬
able to project funds —
For services rendered during the period specified above as stated in "Gross amount
earned " column....
NOTATIONS
Differences-
Account verified; correct for.
(MEMORANDUM)
PAY ROLL FOR ACCIDENT COMPENSATION PATROU.NO
Didtr Ik* prnWn* *f Ik* E-»l*7***' C«»***all** Ad of htluto T. 111! rt* Bttt 741), ** »nM kf Ik. art .f Ftkwy If, ItM
(48 BUI. Ill), u uud«l kr Ik* **t *r Aforu », 1688 (46 But. Ill) P.„. Kn
Aumrr WOHKB nOUtll ADMINISTRATION ... _ . , ..
Duiiwino Omen Fob Period From to - Ikclubiyr.
Nam* i» Add*— of EnnoTRB
Su
U o« F
ACCIDENT OCCURRED
PERIOD COMPENSATED TOR
of Dat»
^ btakbau
Aaourof
Pais
C™* DunM* D""
». B. B*
Ok Pmojxer N<ni»u
DAT*
fun
To
(Induiln)
1
2
2
4
5
e
7
8
8
10
11
12
12
14
15
1#
17
18
IB
20
21
22
23
24
|f
§ b-
I
M
p o
* b
|h
n\
?«?
r
I
i
V 1
Sf -
|2
* 3 u? x
■a • E m
g sn -
I1
* Is
»k
a *e
1
r
?
s
3
II
K ?t 8
11 r
-
Totals For Tm» Paoa
——
5?
o
o
p
g. &
MS#
# >3 B
<1 > P-
G> H»
CJ1 M
09 h-i
® H M
1mjju3 i|ullmlmi jj« tuuujd pn> alp jo
X«d jo uiij oi|i )u111 puu ' ||oj slip uo piud pouod aip joj pjniniuoj esq Xiipqmp mji imp 'uuuo<| |k>)U|« iuiiouiu oi|i ui
puo oiiu .up ju puu unputuodiuio O) poppuo A||«4.hj« ojo Xoip |«i|i sijuj oip uiujj pui.oj u-wq »uij 1; imp :»-uoi|opi&u
puu UAJUO OAipiJOXM Al| pjl]ij.»*ojd BU JUJIIIAOpllil.l JO BUOI|l|«IOA j.ipun A'llip JO 4UI| UI pJUIB|<UU SOU II tU I JOJ UOI|M
-uoduioo 01 poppuo oju '..iSuil "— ui '||oj <ml unpiu oip uu jtroddu soujou osoi|* .u"ti«l oip iuip ajuui:> |
ian,.« > ubui
4-m1aj4jjhi
j
ilui aiojoj soi«|g poiiu,} oip jo aooXo|duio u| uopatuodtuoo )u<ippju jo lUouiXld joj
"N i°nn| CB O (1
°.M ll°JI *»«!
uoiifudiuddy
uiimj |«UOJ
(tl I •!»»« •»> Mil 1 ll«*Y J* I" Ml <* "
•(l« 1»IN »») M*l *1 ). ui am <* papaaaa as -iitl -|(ih Ml
II •! jaqaaiSsN J" l»» us|itssa4iiiBj .•*ai«|Uniq a«i |s • uo|>|*aiS am japs
N0LLVSN3dN0D 1N3QDDV MOJ 110H AVd
FAY ROLL FOR ACCIDENT COMPENSATION
Voucher No.
Pay Roll No
D. O. Symbol No. _
Fa On or hum E
Par payment of aoddant compa
aacanty paymanta. Injured In tj
j to snployeaa of tha United State* receiving
ormanc* of doty, aa itamiaed within
MEMORANDUM
Appendix B
WPA 600
cunncation or ilioimlity
TOTAL NUMBER Of PERSONS IN CASE
RELIEF DISTRICT
WPA CERTIFICATION
NYA CERTIFICATION
NAME (LAST) (FIRST)
(MIDDLE)
NAME (LAST) (FIRST)
(MIDDLE)
PRIMARY CLASSIFICATION (INDUSTRY)
IDENTIFICATION NO.
PRIMARY CLASSIFICATION (INDUSTRY)
IDENTIFICATION NO.
SECONDARY CLASSIFICATION (INDUSTRY)
RELATION TO HEAD
SECONDARY CLASSIFICATION (INDUSTRY)
RELATION TO HEAD
VETERAN
YES □ NOtn
SEX
MARITAL STATUS
DATE AND PLACE OF BIRTH
X
SEX
DATE AND PLACE OF BIRTH
CITIZEN (CHECK)
BY BIRTH □
NATURALIZED □
ALIEN—DECLARED INTENT YES □ NO O
DATE PLACE
CITIZEN (CHECK)
BY BIRTH □
NATURALIZED (Z)
ALIEN—DECLARED INTENT YES O NO O
DATE PLACE
OTHER EMPLOYABLE PERSONS (WPA AND NYA)
DATE OF WETH VETEJUN CTTHEM
(SIGNATURE AHOimE)~
WPA Form 600
(Revised)
CERTIFICAIION OF ELIGIBILITY
Deaoription Aotual sixe 8 by 5 lnohesj 1 page, printed
faoe only.
Routing Original and two copies as follows: Original
and first copy to Division of Employment; second oopy
retained by Public Relief Agency.
Instructions for Preparation See Handbook of Procedures,
ohapter XII, seotion 4.
Printed form supplied on request by Works Progress
Administration, Washington, D.O.
Appendix B
WPA 601
WPA Form 001
NOTICE OP CASE CHANGE
Effective Date
, 193...
Case name
, 193—.
Old address
New address
Number of persons in case
Subsequent information:
1
TO WPA
DIVISION OF
EMPLOYMENT
(Signature and title)
(Agency)
WPA Form 601
NOTICE OF CASE CHANGE
Description Aotual site 8 by 5 inches; 1 page, printed
face only.
Routing Two copies as follows; copy 1 to Division of
Employment; copy 2 retained by Publio Relief Agency,
Instructions for Preparation See Handbook of Procedures,
chapter XII, section 5.
Printed form supplied on request by Works Progress
Administration, Washington, D. C,
Appendix B
WPA 602
CANCELATION OF CERTIFICATION OF ELIGIBILITY
Effective Date 193—
The previous certification of this case as eligible for employment on Work Program project is canceled.
(See reason below.)
Cose name Date filled in 193
Address Case No
- Identification No
Reason for cancelation:
1
TO WPA
DIVISION OF
EMPLOYMENT
(Signature and title)
10—tow (Agency)
WPA Form 602
CANCELLATION OF CERTIFICATION OF ELIGIBILITY
Description Aotual size 8 by 5 inchesj 1 page, printed
faoe only.
Routing Three ooples as follows: oopies 1 and 2 to
Division of Employments oopy 3 retained by Public Re¬
lief Agency.
Instructions for Preparation See Handbook of Procedures,
ohapter XII. seotion 6.
Printed form supplied on request-by Works Progress
Administration, Washington, D. C.
Appendix B
WPA 701
WORKS PROGRESS ADMINISTRATION
OF
(Htuto)
STATEMENT OF PROJECT ESTIMATE DETAIL
To: Sequence No. .
State Administrator.
(City)
Date.
(State)
The work project described below has been selected for operation. Your approval of its prosecu¬
tion is requested.
(Designated local officiali
Approved : Office
City..
State Administrator.
Location of Project Location symbol.
(County and city)
Description of Project :
Expected starting date Estimated date of completion
Sponsor
The following identifying symbols shall appear on every pay roll, requisition, or other encumbrance
document chargeable to the project.
Type of work symbol Official project No. Work project No.
Appropriation symbol Title
The following items and amounts comprise the cost estimate hereby approved, of the above-
descrtbed project or portion thereof:
items
man-hours
distribution of funds
total funds
wpa
Sponsor
wpa
Sponsor
Noncertified labor
Total labor
\
Other nonlabor
Total nonlabor
Total approved cost estimate
WPA Form 701
(Revised 9-1-37)
STATEMENT OF PROJECT ESTIMATE DETAIL
Description Actual size 8 by 10j|- inches; 1 page, printed face
only —
Routing Original and four copies as follows; original to
"initiating office; first copy to Treasury State Accounts
Office; second and third copies to Division of Finance;
fourth copy to appropriate operating division.
Instructions for Preparation See Operating Procedure No. F-17.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
S2 ail
i:
It
p
•il::
;l.i'
is s
f •?
• o M
• • »
$.? I
Es I
it I
78 1
H *-
Is "3
A i
3 "5
lis
g*j
His
Appendix B
WPA 704a
WORKS PROGRESS ADMINISTRATION ^ ^ N„
Work Project No.
SPONSOR'S EXPENDITURE REGISTER
&
5
(t)
Dati
Entby
Explanation
(3)
Expsnditdm*
Cash
Dki-omt
(7)
(«)
m
Labor
(«)
Otlior
(6)
ToUl
(0)
l
8
4
6
e
7
e
10
11
12
is
14
16
16
17
18
19
20
21
22
23
24
26
26
27
28
29
30
31
82
33
34
36
36
37
33
39
40
41
42
43
44
46
!
1
1
I
1
ll
!
—
WPA Form 704a
SPONSOR'S EXPENDITURE REGISTER
Deeoriptloa Actual else 12^ by 14 inoheat 1 page, printed
face and reverse aame.
Routing Original only, maintained by Division of Finanoe.
Instructions for Preparation See Operating Prooedure No, F-49.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D« C.
H
s|
8 *
I'
U
•j
8
WORKS PROGRESS ADMINISTRATION
ADMINISTRATIVE EXPENSE REGISTER
State Office
Appropriation gymboL
Sheet No
DVT*
OOCO-
KN0UUBKAN094
UNBNCOMBIRBD
ToocniM
UNLIQUIDATED IKCDUIUHCU
l—
(U
KMT9T
(A
„
(4)
(5)
PD™"1""D'
o™-"
Tom.
AUTUOKIZiTIOm
»0>
"M*
a®
CUB
,
I
9
4
1
4
7
•
•
s
10
%
11
tr °
**■
11
Mi
8
19
?!•
>
14
I
IB
!?
E
14
It
z
«
17
I?1
18
14
s«!
90
IKS
91
11
n
»-
94
•5
s
IS
• ^
94
3 t?
3-
77
fs
f
98
-}'
*
19
k
j
XI
91
91
»
99
94
94
„
95
M
14
n
97
98
93
w
94
40
40
4l
41
41
41
41
41
44
44
48
49
s?
o
©
•o
s s
gg.
£
2
• en u
W0RK8 I'ROGREHH ADMINISTRATION
ADMINISTRATIVE EXPENSE REGISTER
ANALYSIS OF ENCUMBRANCES FOR OTHER THAN PERSONAL SERVICES hi«~I So.—
"BiB0
JMM*.
MAT.
HSMYrM
im
(toi
D „
"T,'"
to,
,
1
3
2
3
1
4
4
3
„
e
7
K
i
10
10
,,
■ i
13
i
13
M
IS
10
,7
in
18
19
19
30
|
20
31
21
32
1
!
22
23
23
21
23
23
30
i *
27
W.
2*
! 1 >
29
1
I*
30
*
31
31
32
22
33
I
73
34
«
35
"I
74
38
i
78
37
W
3K
i
SB
1
D
40
■0
41
|
. j41
42
j
43
1
13
44
45
1
i
1
iL_
Appendix B
WPA 707
Active .
Final ...
WORKS PROGRESS ADMINISTRATION
PROJECT FINANCIAL STATUS REPORT
State Office .
Period from to ....
O. P. No. ..
. Inc. W. P. No. .
701-R
Limitation
(l)
Cumulative
Encumbrances
(8)
Balance
(8)
Sponsor's
Pledge
(4)
Sponsor's
Expenditures
(«)
Unexpended
Balance
(6)
5. Total other.
6. TotaL
7. Man hours—
Estimated
Paid fob
Balance
X
X
X
Presidential limitation $
Unliquidated encumbrances: Payroll $
Last nonlabor encumbrance: Document No. .
Remarks:
Sponsor's unexpended cash deposit $..
Other $
Date Amount $..
(Signed) ......
a n—mis Division of Finance and Statistic*.
WPA Form 707
(Revised 9-1-37)
PROJECT FINANCIAL STATUS REPORT'
Deaorlptlon Actual site 8 by loj inches; 1 page, printed
face only#
Routing Original and one copy as follows: original to ap¬
propriate operating divisionj copy retained by Division
of Finanoe.
Instructions for Preparation See Operating Prooedure No. F-47.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
WPA 709
Page 1 of 2 Pages
WOKKI moOKIH ADMINISTRATION
REPORT OF PHYSICAL ACCOMPLISHMENT
Jseeji»i&i^ wwsssw
Operating .. Diaeontinuad or tranaferrod
Thl» Project la undar lha juriadlclion ol tha: Coordinating Committee I I Educational Dirtaion I 1 Operntiona Dlrlalon [ I National Youth Adminiatration I I
Recreation Diriaion I I Dirlaion of Woman'a and Profaaaional Projacta I I WPA-aponaomd Kadaral Project No. I I
Ending data of raport period ISS...
Location •y- -.—.- - (iimmii
To Faouut Woaaa Paooaaaa AnMiMianuTioM, HaaAiegfon, D 0.
Prom: Woaaa Paooaaaa AoNlMgnuTidi), »a/a — Projaet la: Coraplalad
D—Iplloo of Projaet _
WOHKS PltOORCWI ADMINISTRATION
REPORT OK PHYSICAL ACCOMPLISHMENT
To: Kkruai Work* 1*aoore
From: Works Proorks* Aduini
DwonplkMi of Projocl
WPA Form 709
(Revised)
REPORT OF PHYSICAL ACCOMPLISHMENT
Description Actual size; first page 12 by 21 inches, second
page 12 by 24 inches; 2 pages, printed face only.
Routing Original and one copy as follows: original to
Washington office; copy retained by initiating office.
Instructions for Preparation See Operating Procedure No. F-42.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix B
WPA 710
WORKS PROGRESS ADMINISTRATION
CERTIFICATION OF SPONSOR'S EXPENDITURES (OTHER THAN PAY ROLL)
Official sponsor
Project location
(Stale)
(County) (Town or city)
This report covers expenditures for the period
Official sponsor □ (check only).
Cosponsor □ Name of agency
Other contributor.... □ (check only).
Description
Unit
Quantity
Unit Prick
Amount
$
$
Official project No
Work project No
Type of work symbol
by:
Certification is hereby made that in connection with this project the items listed above have been furnished
... . . , f Works Progress Administration.
without cost to the { XT v .
( National Youth Administration.
Certified:
Project Supervisor.
Posted to sponsor's expenditure register by
« ► wmitiBi nnnin wro« 10—HOBO
WPA Form 710
(Revised 12-15-37)
CERTIFICATION OF SPONSOR'S EXPENDITURES
(OTHER THAN PAY ROLL)
Description Actual size 8 by 10| inches; 1 page, printed face
only.
Routing Original and two copies as follows: original and first
copy to Division of Finance; second copy retained by operating
division. 1 °
Instructions for Preparation See Operating Procedure No. F-23.
Printed form supplied on request by Works Progress Adminis¬
tration, 'Washington, D. C.
Appendix B
WPA 710a
WORKS PROGRESS ADMINISTRATION
CERTIFICATION OF SPONSOR'S EXPENDITURES (PAY ROLL ONLY)
Official sponsor Official project No .
Project location Work project No
(8tate)
Type of work symbol.
(County) (Town or city)
This report covers expenditures for the period by:
Official sponsor □ (check only).
Cosponsor □ Name of agency
Other contributor. .. □ {check only).
PAY ROLL PERIOD
Pat Roll No.
Beoinnino Date
Certification is hereby made that in connection with this project the personal services listed above have been
furnished without cost to the I *ohks pro°''i:s9 Administration.
[ National Youth Administration.
Certified for sponsor by .
Approved Posted to project register by .
(For operating division)
WPA Form 710a
(Revised 12-15-37)
CERTIFICATION OF SPONSOR'S EXPENDITURES
(PAY ROLL ONLY)
Description Aotual siie 8 by 10jt inchesi 1 page, printed face
only.
Routing Original and two copies as follows: original and first
copy to Division of Finanoe; second oopy retained by sponsor.
Instructions for Preparation See Operating Prooedure No. F-23.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. c.
Appendix B
VKPA 710b
WORKS PROGRESS ADMINISTRATION
REPORT ON LIQUIDATION OF SPONSOR'S PLEDGES
Date 193—
Dear Sir:
The amount of the pledge on each work project in operation, expenditures to date, and unliquidated balances
as taken from our records ore shown below. Attached hereto are copies of all documents certifying expenditures
from cash deposits, receipt of materials and equipment, and personal services supplied, during the month without
, J Works Progress Administration.
008 6 I National Youth Administration.
Expenditures of cosponsors and other contributors are included in the amounts shown below.
OrricuL
Pbojict
No.
Work
Pbojict
No.
SPONSOR'S FUNDS
Pledge
(3)
ExriNorroiM, Month or -
Cumulative
Expenditure*
Through
(7)
Unexpended Caah
Depot! te
(8)
nn1lqnH*'H
Balance of Pledge
w
Material*, Equip¬
ment. Eto.
(4)
Personal Service*
(pay roll*)
(»)
Total
(0)
$ - ....
$
$
$
$
$ ...
• Col. 9 equals col. 3 leas cols. 7 and 8
If the amounts shown above are not in agreement with your records, please communicate with the undersigned.
If no reply is received within 15 days this report will be assumed to be correct.
Very truly yours,
WPA Form 710b
(Revised 12-15-37)
REPORT ON LIQUIDATION OF SPONSOR'S PLEDGES
Description Aotual sise 8 by lofe inches; 1 page, printed face
only.
Routing Original and two copies as follows: original to sponsor;
first oopy to operating division; second copy retained by
Division of Finanoe.
Instructions for Preparation See Operating Prooedure No. F-23.
Printed form supplied on request by Works Progress Administra¬
tion, Washington, D. C.
Appendix B
WPA 717
WORKS PROGRESS ADMINISTRATION
MONTHLY REPORT OF ADMINISTRATIVE EXPENSES
Local office.
State office ..
All c
Account..
State
Month.
Program classification No Appropriation symbol.
CLASSIFICATION
(1)
A.—Encumbrancer:
01 Personal services
Other Encumbrances:
02 Supplies and materials...
PAST MONTH
05 Communications- -
06 Travel expense
07 Transportation of things...
08 Printing-and binding
10 Heat, light, water, power, and elcctricity-
11 Rents—
(a) Buildings. —
(b) Equipment—
12 Repairs and alterations...
13 Special and miscellaneous-..
(Explain on reverse side)
30 Equipment
Total—Other Encumbrances...
Total Encumbrancer
B.—Unliquidated Encumbrances:
Personal services $
Other — $
Total $.
CURRENT MONTH
CUMULATIVE TO DATE
C.—Status or Funds:
Authorizations Rec'd... $..
Encumbrances — S...
Balancc end of month. $...
Submitted...
Director of Finance and Slalietica.
W?A Form 717
(Revised 9-1-37)
MONTHLY REPORT OF ADMINISTRATIVE EXPENSE
Dosoription Actual size 8 by lOg inches; 1 page, printed faoe
only.
Routing Original and three copiesj original and first copy to
Division of Finance and Accounts, Washington, D. C.; second
copy to Regional Field Officej third copy retained by initi¬
ating office.
Instructions for Preparation See Operating Procedure No. F-33.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
WPA 718
WORKS PROGRESS ADMINISTRATION
MONTHLY REPORT OF EMPLOYMENT AND EARNINGS OF
ADMINISTRATIVE PERSONNEL
Consolidated report * General administrative State ....
State office report General project supervisory
Local office report NYA administrative Month .
(Designation of local office)
z
Division and Section
(2)
Number or
Number or Persons Paid
3
(»)
Status Last
Day or Month
(3)
First half
of momb
(4)
Second half
of month
(B)
Entire Month
(6)
(7)
WPA Form 718
(Revised 3-15-36)
ADMINISTRATIVE PERSONNEL ANALYSIS
Description Actual size 9 by 16 inohes; 1 page, printed
faoe only.
Routing Original and two copies as follows; original to
Washington,
second
Division of Research, Statistics and Records,
D, C•j first copy to Regional Field Representative;
copy retained by State Works Progress Administration.
Instructions for Preparation See Operating Procedure No. S-]2.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Part time and per diem employees (not
included above)
Prepared by
(Title)
Approved
State Statistician.
. Approved
Slate Administrator.
Appendix B
l/VPA 723
A. IDriu 7*1
WORKS PROGRESS ADMINISTRATION
FEDERAL THEATER PROJECT
Work Project No.
Matinee
Evening
DAILY BOX-OFFICE STATEMENT
(Attraction) (!>»U o/ |>w(ormau»
(Theator or auditorium hotulnc attraction) (C)ty) (8taU)
Capaovt
""°"
Kbt»bu«bh) Scale
Special Rate
Til
Sold
Prloo
Bold
Prloa
—
OrcNixo No.
Cloboio No.
Totals this pcrforn
Total to date
Totul receipts this performance $
Federal Theater Project share % ,
Lessor's share %
We hereby certify that the abovo statement is correct:
Truuurer. Agent Cashier.
Amount to be deposited by agent cashier from box-office receipts for this performance ..
WPA Form 723
DAILY BOX-OFFICE STATEMENT
Description Actual siie 8 by 12^ inchesj"1 page, printed
face only.
Routing Original and three copies as follows: original to
Division of Financej first oopy to project supervisor;
aecond copy to agent-cashier; third oopy retained by
box-office treasurer#
Instructions for Preparation See Operating Procedure No. F-45.
Printed forn supplied on requost by Works Progress Adminis¬
tration, Washington, Da C.
WORKS PROGRESS ADMINISTRATION
Section ....
Sheet No. .
REPORT OF FINANCIAL TRANSACTIONS AND FUND STATUS
MONTH OF YEAR
State
Date Prepared
Available balance beginning of month—
Total authorizations rocoivod during month
Authorization No. ...—...
Authorization No
Authorization No
Authorization No. —
Authorization No. —...
Authorization No
Authorization No
Authorization No
Total to be accounted for_
Encumbrances—personal services (net)
Encumbrances—"other" (net)
Total encumbrances ..
Available balance end of month
8 Unliquidated oncumbrancos—personal services. .
0 j Unliquidated encumbrances—"other"
xxxxxx
XX X X XX
xxxxxx
xxxxxx
xxxxxx
xxxxxx
XXXXX X
xxxxxx
APPROPRIATIONS OR DESIGNATED OFFICIAL PROJECTS
ft
Ve
3 8 ?a
o *5-
rt-«-? o ®
o ®
§ 3~ o
=S o
Is
5
M, 5- O 3
"lif
? O1 O O
§ £
$
a a
h- a a
o°
a a ® o
1
f?r§ a
%'E
a
*t
4
qa .J
® O H- ®
•1 ®
P M P
I
£
f
£
* 64 S3
7 S 3 8 3
8 • ! 6
a a <*■ o
%
« its
• III
I pctO.
£ l8
[IS
§3*
ST
(Signed) ..
(Signed)
SUU Dndar •/ Fwwk« mai S
StaU Adminittralar.
>
V
— U
H *
> Os
w
Appeadix B
WPA 725
WPA FORM 725
WORKS PROGRESS ADMINISTRATION
OTHER INCOME STATEMENT
Attraction
Theatre or auoitorium
work project no.
Date of Receipt of funds_
Contributions (Other than co-sponsor*s) $.
concessions
Program advertising
Other (Specify)
TOTAL OTHER INCOME
i hereby certify that the above statement is correct.
rusiness Manager - Agent Cashier
WPA Form 725
OTHER INCOME STATEMENT
Description Actual size 8 by 10% inches; 1 page, face only#
Pouting Original and two copies as follows: original to
Division of Finance; first copy to project supervisor;
second copy retained by agent cashier#
Instructions for Preparation See Operating Procedure No# F-45.
Form to be duplicated by State Works Progress Administration.
WPA FORM 726
Official Project no,-
work project no.
WORKS PROGRESS ADMINISTRATION
DAILY PASH ADMI5SIONS RECEIPTS
Sales for tonights
PERFORMANCE
ADVANCE SALES (Fig IN,
i3.
3b
datfs at hfad of coiimns markfh i to 7)
Total Cash
Receipts
no. Sold cash
Cash no. Sold
cash |no. Sold
Cash
^o. Sold
Cash
No. Sold Cash no. Solo
no. sold cash
WPA Form 726
DAILY CASH ADMISSIONS RECEIPTS
Description Actual size 14 by 8 inches; 1 page, face only.
Routing Original and two copies as follows: original to Di-
vision of Finance; first copy to agent cashier; second
copy retained by box-office treasurer.
Instructions for Preparation See Operating Procedure No. F-45.
Form to be duplicated by State Works Progress Administra¬
tion.
lessor's Share
Federal Project Share
lessor's Agent
Appendix B
WPA 727
WPA FORM 727
WORK8 PROGRE88 ADMINISTRATION
RECORD OF BIDS RECEIVED
Req. no
BY TELEPHONE
Req. Date.
bio da te
TOTAL COST
bios made by
signature
Awards Made By_
Signature Business Manager-Agent Cashie
WPA Form 727
RECORD OF BIDS RECEIVED BY TELEPHONE
Description Actual size 8 by 10| inches; 1 page, face only.
Routing Original and one copy as follows: original to Treasury
state Accounts Office together with payment voucher; copy
retained by agent cashier.
Instructions for Preparation See Operating Procedure No. F-45.
Form to be duplicated by State Works Progress Administration.
Appendix B
WPA 728
*P« FORM 728
WORKS PROGRESS AOMIN18TRATI ON
BUSINESS MANAQER - AQENT CASHIER'S
CONSOLIDATEO REPORT
period covered BY Til 18 report
official project no. from
State of t0
Number of Agent cashier Accounts included in this report
total amount of advance made by 0i8bursinq clerk $
admiss ions
Available Funds
Ourino Perioo
Cash
Disbursements
commitments
1034 voucher
Balance
Unexpended balance Last Report
admissions collected
Other Income
Disbursements
Unexpended Balance
Sub totals
federal funos
unexpenoed last Report
Encumbered During Period
Disbursements
Unexpenoeo Balance
sponsors contribution
Unexpended Last Report
Encumbereo during period
Disbursements
Unexpended balances
totals
disbursements & commitments
admissions
Federal
Sponsors
1034
Cash
1034
cash
1034
materials & Supplies
Travel
Rent
Advertising
Emergency Employment
Miscellaneous (Explain)
totals
i hereby certify that thi6 report is correct ano true ano that the agents accounts have been
examined by this office.
Signature of Finance Officer
WPA Form 728
BUSINESS MANAGER-AGENT CASHIER'S CONSOLIDATED REPORT
Description Actual size 8 by 14 inches; 1 page, face only.
Routing Sriginal and two copies as follows: original and first
copy to Division of Finance and Accounts, Washington, D.C.;
second copy retained by State Division of Finance.
Instructions for Preparation See Operating Procedure No. F-45.
Form to be duplicated by State Works Progress Administration.
Appendix B
WPA 730
No. ...
Date .
193..
DISTRIBUTION OF STATE MONTHLY BUDGET
TO:
(Dedgnatod local official)
You are authorized to encumber for the month of .
. the following amounts.
This authorization represents the maximum amount which may be encumbered during the month.
appropriation symbol
personal services
other than personal
service8
total
\ /
\ /
\ /
\ /
\ /
\ /
v
\/
A
/\
/ \
/ \
/ \
/ \
/ \
Total,
Slate Administrator.
WPA Form 730
(Revised 9-1-37)
DISTRIBUTION OF STATE MONTHLY BUDGET
Description Actual size 8 by lOjg inches; 1 page, printed face
only.
Routing Original and two copies as follows: original retained
by State Administrator; first copy to Division of Finance;
second copy to local administrative office.
Instructions for Preparation See Operating. Procedure No. F-15.
Printed form supplied on request by Works Frogress Adminis¬
tration, Washington, D. C.
Appendix B
WPA 732
WPA Form 732
WEEKLY REPORT OF EMPLOYMENT ON WPA PROJECTS
State Official Project No -
District - Work Project No.
County - - Section No
Weekly report of the number of persons employed on above project as of Wednesday,
, 193-,..
(Date)
CERTIFIED
NONCE RTIFI ED
TOTAL PERSONS*
VOL. ABSENCES
BEYOND 5 DAY'S
Male
Female
Male
Female
• Exclusive of voluntary absences beyond 5 days.
gpo jo—6245 Signed
THIS REPORT MUST BE MAILED NOT LATER THAN WEDNESDAY NOON
WPA Form 732
WEEKLY REPORT OF EMPLOYMENT ON WPA PROJECTS
Description Actual size 5jg- by 3-J inches; card, printed face
only.
Routing Original only, to Division of Finance.
Instructions for Preparation See Operating Prooedure No. S-l.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
II
PJ
1" 2
iff
\
[
§
f-
>- m
3 e
?ii"
To
i
8"Z
a
I,
: s a
§
• 3
■si I;
SS X °s
I
> a
S3
5
3
WORKS PROGRESS ADMINISTRATION
FUND CONTROL REGISTER
Program Cluai&cation...
z
D«T»
Doco-
EHTDHHUHTU (HOT)
RBCOTU
IUPIIOI Moktb.
Net Chan
Sco
uhuoxidatu
|
<S
sc
No.
Labor
Other
ToUl
DlU"C'
Labor
Other
Labor
Other
(!)
(IS
(4)
(«)
(is
(IIS
1
I
1
1
I
r ~
\
! »
« 1
I )
| 1
1 1
j i
1 !
1 \
1 1
i
..
»
1
1
1 •
\ i
l
i
f
(
1
i
»
1
' I
"I1
1
f i
« i
J
!
r
H*
r
!
n
i |
f
S4
1
1
f
1 l
i i
ST
... ....
. ! J
1 1
SS
i I
1 1
.
1
1
j
40
i
k
41
1
f
42
1 1 t
1
1
I
1
t
-I
1
1 ! I
i
1
i
4S
Ill
¥
i!
If
si
f'
:i
WORKS PROGRESS ADMINISTRATION
BUDGET DISTRIBUTION REGISTER
Broom Hbciita
Acnoaiunoim Rbcbitbd
rj 3-
• 3- B
?r i
h 1
51
V p >
!: f
If
Labor
(D
Othar
(1)
Total
Appropriation
Symbol
Amount
*BTOOIT°*
or Doo-
(ID
labor
(U)
Other
(ID
Total
(ID
Labor
(ID
Total
(ID
-
-
=
1
-
-
1
-
-
-
1
-
1
-
-
-
-
1
-
-
=
-
-
-
J
-
I
>
T3
-S ^
5 e
t-N
3"
Oi »
a
3
CL
•>3
W
-3
W
WORKS PROGRESS ADMINISTRATION
SJIJI
**
3 agpa
It
SI?8 83
§£
B8||)S
ft
r-r i
p.
£l
?S: 5-
£
5o8 *
;§
• 2
s5l ^
?
: *:
I i
3'
f S £
*<r|
I -
?£!!
8
ffi
P3
<a
JOURNAL VOUCHER
NOT Chajioi I
uvuqcidatvj
Phooraii Cussi-
ehauui
Thie Period
Cumulative
Thle Period
Cumulative
Thia Period
Cumulative
labor
Other
labor
Other
(3)
(»
(3)
(II)
(13)
1
T
r
...
1
1
....
1
j
1
i
!
1
|
! i
|
□
'
77
1
!
71
1
11
I
1
|
1
1
|
"1
11
'
I
1
i
57
1
! 1
! |
1
38
! 1
1 l
1
1 1 1
l !
<3 H
oa
cd w
Appendix B
WPA 739
WPA Form 788
WORKS PROGRESS ADMINISTRATION
REPORT OF PROJECTS COMPLETED, DISCONTINUED, OR TRANSFERRED
TO: Accountant in Charge,
U. S. Treasury, State Accounts Office:
Month or , 193....
State ..
The following projects have been completed, discontinued, or transferred. You are authorized to close these
accounts and to accept no further encumbrances on same excepting adjustments incidental to liquidation.
OmcUL Project No.
Work Project No.
OmciAL Project No.
Work Project No.
Report initiated by:
Division of Finance and Statistics.
Operating Division.
Approved: .
For the State Administrator.
WPA Form 739
REPORT OF PROJECTS COMPLETED, DISCONTINUED,
OR TRANSFERRED
Description Actual size 8 by lOg inches; 1 page, printed face
only.
Routing Original and three copies, as follows: original to
Treasury State Accounts Office; first copy to Division of
Finance; second copy to appropriate operating division;
third copy retained by initiating office.
Instructions for Preparation See Operating Procedure No. F-47.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
WPA 750
WPA FORM 750
Report no._
paoe no. of paqe6
Date .19
WORKS PROGRESS ADM INI8TRATI ON
S f ate
REPORT OF OFFICE FURNITURE AND MECHANICAL EQUIPMENT NOT IN USE
The following equipment is not now in use and is surplus to the needs of the Work6 Progress
Administration in this State.
State Administrator
State Director of Finance
Property
Ser ial no.
Estimated
Cost of Repair
WPA Form 750
REPORT OF OFFICE FURNITURE AND MECHANICAL
EQUIPMENT NOT IN USE
Description Actual size 8 by 10^ Inches; 1 page, face only.
Routing Original and 1 copy as follows: original to Division
of Finance and Aooount?, Washington, D. C,j copy retained
by initiating office.
Instructions for Preparation See Operating Procedure No, F-51
Form to be duplicated by State Works Progress Administration,
Appendix B
WPA 950
Page 1 of 2 Pages
wpa
FORM 950
WORKS PR0GRE8S ADMINI8TRATION
CLAIM FOR LOSS OF OR DAMAGE TO PRIVATELY OWNED PROPERTY
$1,000. OR LESS
the
works progress administration date
Washington, t). c.
i present the following for consideration under the provisions of the act of december-
28,
1922 ( 42 Stat. 1066):-
claim for "Loss of" "Damage to" (cross out one) Private Property
1.
full name of claimant
2.
address
City county State
3.
Amount of cla im $ Date of loss or damage
4.
Name of employee causing damage
5."
payroll identification of employee causing damage
6.
number and character of project
7.
location at which loss or damage occurred
8.
description of property lost or damaged (if property is real estate, evidence must be sub¬
mitted to prov^ claimant is record owner). *
9.
use being made of property when loss or damage occurred
1C.
character of damage
11.
Full circumstances surrounding damage
12.
method by which value of lost property or amount of damage was established (if appraisals,
receipted bills, or other evidence is relied upon to establish value, the supporting papers
should be marked exhibits and referred to in the statement under this heading).
13.
names and addresses of witnesses of the accident or event resulting in the damage, or of the
principal witnesses in case of a considerable number.
14.
was property insured? yes no if so, amount of policy
name and address of insurance company
has all or any part of loss or damage been paid by insurance company?
No Yes Amount
What is the status of claim for loss or damage against the insurance company?
Filed? Pending? Rejected?
if claim rejected or not filed, state reason,
WPA Form 950
CLAIM FOR LOSS OF OR DAMAGE TO PRIVATELY OWNED PROPERTY
Deeoription Actual eite 8 by 10£ inoheej 2 pages, face only.
Routing Original and two oopies as follows! original to Works
Progress Administration, Washington, D. C.j first oopy to
State Administrator! second oopy retained by initiating
office.
Instructions for Preparation See Operating Prooedure No. F-39.
Form to be duplicated by state Works Progress Administration.
Claimant's certificate: i certify that to the best of my knowledge the above ib a true
and correct statement of the circumstances surround inq the damage sustained; that i am not
aware of any material fact contributing either directly or indirectly to the cause of said
damage which is not particularly set forth herein or in attached papers; and that i have re¬
ceived no payment from any source for the whole or any part of the damages sustained.
(Claimant)
Subscribed and sworn to before me this day of
(signature)
(Official Seal)_
(Title of official administering oath)
Note: all claims presented must be determined as legal claims; it is necessary that evidence,
preferably in affidavit form, be submitted to substantiate all material fact6. the claimant
must also include with this evidence, all correspondence with any officer of the works progress
Administration with relation to this claim.
NOT TO 3E FILLED OUT BY CLAIMANT.
1. in your opinion was the WPA employee acting within the scope of his employment? YES No
2. if so, was the loss oue to negligence OF WPA employee? yes no
3. was the claimant negligent, and if so, did his negligence contribute to the loss or damage:
(Explain on separate sheet if necessary.) yes NO
4. | recommend that the claim be: approved for $ _ disapproved
5. Remarks ano furti-cr recommendations:
designated WPA official
Recommendations by State works Progress Administrator:
1 . i recommend that the foregoing claim be:
Approveo for $ Disapproved
Remarks and further recommendations:
Appendix B
WPA 955
IOHH m W0RKS pR0GRES8 ADMINISTRATION 193
(month)
MONTHLY REPORT ON ADMINISTRATIVE COSTS INCURRED BY WPA COMPENSATION
SECTIONS /.NO NUMBER OF COMPENSATION CASES HANDLED FOR WORKS
PROGRESS AND FARM SECURITY ADMINISTRATIONS
State Local Office
STATEMENT A - ADMINISTRATIVE COSTS AND NUMBER OF ADMINISTRATIVE PERSONS EMPLOYED
L
1
N
ITEM
(1)
STATE OFFICE
LOC
*L OFFICE
t01
AL
number
(2)
Amount
0)
Number
(4)
Amount
(5)
Number
(6)
Amount
(7)
1
PERSONAL SERVICES
Full time
2
part time
3
TOTAL
4
Travel Expenses
xxxxxx
xxxxxx
xxxxxx
5
Other Expenses
xxxxxx
xxxxxx
XXXXXX
6
TOTAL
xxxxxx
xxxxxx
xxxxxx
STATEMENT'S - NUMBER OF COMPENSATION CASES
lost
t 1 me
no lost time
no lost t1 me
but medical
nor med. or
n
e
item
or hospital
hosp.
Expense
t 0 t a
L
Expense
Reported on m
wpa
fsa
wpa
fsa
wpa
fsa
wpa
fsa
total
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
7
Active cases, first of Mo.
xxxxx
xxxxxx
8
new cases
9
reopeneo Cases
xxxxx
xxxxxx
10
Total cases handled
11
closed cases
12
active Cases, End of mo.
xxxxx
xxxxxx
NOTES:
Line 2 - Enter the number of Administrative persons who devote part time to compensation claim
work and the amounts they earned for performing such work.
line 4 - include per oiem allowances for travel expense.
line 5 - include such charges as telephone, telegraph, rent, etc.
Line 7 - Represents cases: (a) Receiving compensation locally or from Washington; (b) where medi¬
cal treatment or hospitalization is still being rendered; (c) where investigations are
still in progress or (o) where all expenses have not been submitted to the united states
Employees' Compensation Commission at Washington, 0, C. The entries on this line must
equal the ntmber of compensation cases reported on line 12 of report for previous month.
Line 8 - Enter all cases reporteo ouring month irrespective of date of injury,
line 9 - Enter the number of cases previously reporteo as being closed suf in which lost time
developed, or medical or hospital treatment was required, or subsequent investigations
were necessary, our i'ng the month covered by this report.
Line 10- this line is the'sum of lines 7, 8 and 9.
Line 11- Enter the Dumber* of cases for which all payments of compensation due locally or from Wash¬
ington have been maj5e, no further medical treatment or hospitalization is required, all
investigations have been completed, and all expense6 incurred have been submitted to
Washington.
Line 12- Enter all cases which had not been closed at the end of the month. The number entered on
this line must equal the number entered on line 10, less the number entered on line 11.
Date issued
State compensation Officer
State Director of Finance
WPA Form 955
MONTHLY REPORT ON ADMINISTRATIVE COSTS INCURRED BY WPA
COMPENSATION SECTIONS AND NUMBER OF COMPENSATION CASES
HANDLED FOR WORKS PROGRESS AND
FARM SECURITY ADMINISTRATIONS
Description Actual size 8 by lOg- inches; 1 page, face only.
Routing' Original and three copies as follows: original and
first and second copies to Compensation Section, Division
of Finance and Accounts, Washington, D, C.; third copy
retained by State Compensation Offioe.
Instructions for Preparation See Operating Procedure No. F-35.
Form to be duplicated by State Works Progress Administration.
Appendix B
WPA 955A
WPA FORM 955A
WORKS PROGRE68 ADMINISTRATION
SCHEDULE OF FARM SECURITY ADMINISTRATION INJURY CASES INVOLVIN«
LOST TIME, MEDICAL OR HOSPITAL EXPENSE
(AS reported on line 8, columns 12 ano 14 OF WPA form 955)
State month of 193
Employee^ Name
project
Date case receiveo oy local wpa
WPA Forir. 955A
SCHEDULE OF FARM SECURITY ADMINISTRATION INJUPY CASES
.INVOLVING LOST TILE, MEDICAL OR HOSPITAL EXPENSE
<Description Actual size 8 by 10g inches; 1 page, face only.
Routing Original and three copies as follows: original and
~ fIFst and second copies to Compensation Section, Division
of Finance and Accounts, Washington, D. C.; third copy
retained by State Compensation Office.
Instructions for Preparation See Operating Procedure Ho. F-35.
Form tc be duplicated by State Works Progress Administra¬
tion.
Appendix B
WPA 956
WPA form 956
WORKS PROGRESS AOMINI8TRATICN
MONTHLY REPORT ON CLOSED COMPENSATION CASES
State month of 193
Name of Injureo
Date
of
injury
Days
Lost
Will Further Payments of Compensation
be made by the U.S.E.c.C.
Compensation Officer
Date prepareu i93_
Director of Finance
WPA Form 956
MONTHLY REPORT ON CLOSED COMPENSATION CASES
Description Aotual size 8 by 10^ inches; 1 page, faoe only.
Routing Original and one copy as follows: original to Com¬
pensation Section, Division of Finance and Accounts,
Washington, D. C.; copy retained by State Compensation
Office.
Instructions for Preparation See Operating Procedure No. F-35.
Form to be duplicated by State Works Progress Administra¬
tion.
APPENDIX B
COMPENSATION FORMS
Appendix B
Compensation C. A. 1
EMPLOYEE'S NOTICE OF INJURY AND ORIGINAL CLAIM FOB
COMPENSATION AND MEDICAL TREATMENT
(To be ■ubmlttod to the official superior by every employee Injured in the performance of his duty, or some one on his
behalf, within forty-eight hours after the injury. This notice shall be given by delivering it personally to the official superior
or by depositing it in the mail properly stamped and addressed to the official superior. It should be retained by the official
superior unless the injury causes disability for work beyond the day or shift in which the injury occurred, or results in any charge
against the Commission for medical expense, when it should be forwarded to the United States Employees' Compensation Com¬
mission with report of injury, Form C. A. 2.)
(Oily or town) ' (StoW)"
(Btroat sad number)
. , 19.
(Date of this notice)
I hereby certify that I was injured in the performance of my duties on , 19.
(D»U)
, m.
(Day of weak) (Hour, a. m. or p. m.)
1. The injury occurred at
(Giro of establishment where employed)
in the following manner:
2. Cause of injury..
3. Nature of injury..
Compensation Form C# A. 1
(Revised 4-27-29)
EMPLOYEE'S NOTICE OF INJURY AND ORIGINAL CLAIM
FOR COMPENSATION AND MEDICAL TREATMENT
Description Actual sire 8^ by 14 inches? 1 page, printed face
only.
Routing Original and one copy as follows: original to Compen-
sation Section? copy retained by project or local adminis¬
trative office.
Instructions for Preparation See Operating Procedure No. F-35.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
4. Names of witnesses to injury:
5. If this notice was not given within 48 hours after the injury, explain failure to give notice and state
the name of the peraon to whom first notice was given and date:
This injury was not caused by my willful misconduct, intention to bring about the injury or death of
myBelf or of another, nor by my intoxication, and I hereby make claim for compensation and medical treat¬
ment to which I may be entitled by reason of the injury sustained by me.
(Name)
Before compensation is paid, written claim on Form C. A- 4 must be submitted to the Commission
111770 0 U S GOVYXMUCXr PWKTIN6 OTDCt 1S3.
Appendix B
Compensation C. A. 2
Face and Reverse
OFFICIAL SUPERIOR'S REPORT OF INJURY
ITs bs nibinlttod to Vmttn llllll Rurintbll' CouriMiTtOM Comhimiok, Wwiblnilon, D. 0., as soon u piMllmbls aftsi sop Injury to ■ drll •opIoyM °<
UnlUd iuim nvtaload wblto lo lbs pwformaDM H duly "bleb osum soy disability (or work bsyoud i ho day or ibin on wbloh lbs Injury ooourrsd or nsulla In any oh
oamlm! I ho Cooimlaloo lor mod tool oipsaoo Tblt loocn should bo aoeoenpaatod by C. A. I.J
1. Department 3. Bureau o
tIPar, rVory, Mr.)
3. Plnco of cihploy mont
4. Reporting office ....
(JfSftaI". Aooloarloi
Not t Vui, OK.)
7. Ago 8. 8c* 9. Raco —
11. Occupation and division ..
12. Was employee doing ills regular
work?...
The injured
13. Total length of service with tho Government as a civilian!..
14. llotv long at present work in this establishment! ~
13. Dates of othor injuries „
f
10. Roto of pay on dato of injury S...
17. Employao begins work at..
19. Hours worked per day
{and subsistence valued at
and quarters valued at 8
13. Regular day's work ends
20. Days paid per week
21. Place where injury occurred ———
(Giro iraa tonUtoa, u tool
22. Date of injury 19 ; day of week
23. Dote employee stopped wotk 19 ; day of week
24. Date employee's pay ctopped 19 ; day of week
25. Has employee returned to work?—_ _... —
; hour of day
; hour of day
(6) Sick leave
(c) Any other reason
27. Describe in full how injury occurred ..
(OiMai
28 State part of body injured and nature and ox tent of injur/ .
The jajiry 29. Did injury cause loss of any member or part of member? — If so, describe exactly
30. Was employee injured while in performance of duty! If not, or in doubt, give detailed statement
(3) Intention of employee to bring about Injury or death of
himself or another? (c) Employee's Intoxication!
(//•n| usurer* to Mar (vrKtosr «" msSr In Mr affhtnallrt, Mr rrporlln# afflrrr itsuli tltorb on atfUtonc! rtolronrsr obis# Mr rruwn /or lb rwnrlnrlon)
32. Was written notice of injury given within 43 hours! If not, did immediate superior have actual knowledge
of Injury? ........—
If nolle* mi not rbm vIMtn JS kovi)
irrciilklltt Kill rwn/lna* /or morr Mon onr tar, box lltUvunU o/vilnrurr mat, on rturu ilia o/MU/oraj
34. Was Injury caused by a third party othor than a Government cmployoo or agency? If so, has employee
36. Nome and address of physician who first attendod
Medial 36. How soon after injury?
nllriutiiu* ^ -j-0 what hospital sent?
Compensation Form C. A. 2
(Revised 6-15-29)
OFFICIAL SUPERIOR'S REPORT OF INJURY
Desoription Actual size 8^ by 14 inches; 1 page, printed faoe
and reverse.
.Routing Original and one copy as follows: original to Compen¬
sation Seotion; copy retained by project or looal admin¬
istrative office.
Instructions for Preparation See Operating Procedure No. F-35.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, 0. C.
57212 0—38 12
STATEMENT OF WITNESSES
r, If ho did not am the Injury o
Signed thia day of ..
Signed thia day of 10
STATEMENT OF GOVERNMENT MEDICAL OFFICER OR PHYSICIAN WHO FIRST
EXAMINED CASE
__. r aa given fi rat-aid treatment, or examined,
iMwifmikiw)
dicabflitv will b<- .. .
Nature of injur) aa found on examinaiio
Hospitalised Will return for further treatment
Discharged Other disposition _____
Signed this day of 19
Appendix B
Compensation C. A. 3
REPORT OF TERMINATION OF TOTAL OR PARTIAL DISABILITY.
( Cnu 9Ul otw.)
[To bo lonrudtd to the Untthd Statm Emtlotim' OomNiinoii Oommuiion, Wabiithotoh, D. 0., through offlcUl channel*, u
an u durability from Injury terminmUo. ThU form to be eubmltted (or each injury resulting in any diraLility, whether or not employee
lira claim (or com puliation.]
1. Department 2. Bureau or office..
( H*r, "•*,<*.)
3. Placo of employment...
(irmil, Jhif Yard, Oe.)
4. Full name of injured employee
5. Time of injury
6. Time employee stopped work...
(MO (JMprtmeek.) (Bemr.m.m.erp.m.)
7. Time employee's pay stopped ,19 J
(Mi.) (fif/mtk.) (ttwr,«. re.tr p. m.)
8. Firet day employee was able to resume work — , 19 J
(Mi.) (Dtp 4 week.) (flw.a. m. or p.m.)
9. Did employee return to the same work and at same rate of pay after termination of disability!
If so, when ! If not, state character of work performed upon return to
duty and rate paid employee for such work
10. Actual time disabled (including Sundays and holidays) dayB.
11. Number of days for which employee would hare received pay had ho not been disabled dayB.
12. If employee was receiving subsistence as part of his wages, was such subsistence furnished during entire period
of disability! If not, give dates on which subsistence was not furnished. „
13. Has employee been paid for any portion of above absence on account of—
(o) Annual leave I
(OI«aSM.)
(ft) Sick leave!
lot— < ran imj
(c) Any other reason :
14. Nature of injury
16. Remarks
file following information is to bo furnished only in case of death resulting from an injury sustained while in the performance of duty.
If death results immediately, or if no Report of Injury has previously been submitted, such report, on Farm 0. A. 2, should be forwarded
herewith.]
REPORT OF DEATH
16. Full name of deceased empbyee ..
17. Time of death
19. Place of death
20. Immediate cause of death.
(Btmr, a. m. tr p. m
21. Widow of deceased empbyee
IMMmw.) u«w)
22. Children of deceased empbyee under 18 years of age, or those over 18 who are incapabb of self-support:
Atafc. Apt.
23. Names, relationship, and addresses of all other persons known to be dopendent, in any degree, upon decedent
at time of death:
Nam*. Rilatumehip. Addr***.
Signed this day of ..
(All forwarding indorumenl* to be mad* on revert* ride of tkU ehoeL)
Compensation Form C. A. 3
(Revised 6-3-26)
REPORT OF TERMINATION OF TOTAL OR PARTIAL DISABILITY
Description Actual site 8& by 14 inohes; 1 page, printed face
only.
Routing Original and two copies as follows; original and first
oopy to Compensation Seotion; second copy retained by project
or looal administrative office.
InstruotIons for Preparation See Operating Procedure No. F-35.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
Compensation C. A. 4
Face and Reverse
CLAIM FOR COMPENSATION ON ACCOUNT OF INJURY
[To b« fllid with Iho ofllclnl luperlor, within 00 day* after tha Injury caualng dlaablllly for moro than threa daya, for tranamlMloo to tha
UNITED STATES EMPLOYEES' COMPENSATION COMMISSION]
CLAIM MUST BE FILED WITHIN ONE YEAR AFTER INJURY
NOTICE:
II of IhoCompanullon Ail of Soptombar T, I
4nf il to bo I alio, ahall ba guilt, of par jury at
• than ana raar, or br both audi fina and Imp
1. Name of injured omployco 2. Ago 3. Sox
|OM M»< I|/UU|
4. Mail address...
6. Married, rin^lo, widowed. 8. Race 7. Occupation and division..
8. Do you apeak English? 9. If not, what language?.„
(and subsistence valued at $...
, ....
and quarters valued at 8
11. Time of injuty
12. Disability for work began ..
| Oa|r o/ not)
"Yoii't/Vuii"
13. First able to resume usual occupation , 10...
(Da I<1 I Day of atrk] [Hour a. ai or p. ai.J
14. First able to do any work 19 . m.
(Do,,| (Days/irnil |f/ra/a. m. try. m.|
15. Period for which compensation is claimed. From to
10. Have you received any pay during period of disability:
On account of annual or sick leave Dates Total amount, 5
Specify any other reason Dates Total amount, S
17. Were you furnished subsistence during period of disability? If so, give dates on which sub¬
sistence was furnished .
18. If medical, surgical, or hospital service was furnished by private physicians or hospitals, state amount of
expense incurred, S and submit an itemized bill for this service with an explanation of reason
for not using United States medical officers or hospitals, if available.
19. If transportation and other expenses necessary to enablo you to secure proper medical and hospital treatment
were incurred by you, state amount of expense so incurred, 8 If reimbursement is claimed
submit itemized receipted bill for such expenses.
10 ttu, plot / pa i. f* p ittaJmml) I t < P I I prsptr
20. Place where injury occurred
21. Cause of injury
22. Nature and extent of injury causing disability
23. Have you made claim against any person for damages on account of the injury described above?
If you have received any money in payment of damages, state amount, S
24. Have you ever been in the military or naval service? If so, give periods served and whether you aro receiving
compensation or a pension for such services
25. Have you mado application for retirement, or received annuity on account of retirement?
26. Dates of other injuries, if any, on account of which you have made claims for compensation.
I hereby make claim for compensation on account of the injury described above, which was sustained by me
while in the performance of my duty for the United States, said injury not being due to willful misconduct on
my part or to my intention to bring obout the injury or death of myself or another, or to mv intoxication. I have
been disabled on account of this injury and have not refused or foiled to perform any work I was able to do during
the period for which compensation is claimed and every stutcment set forth above in support of my claim is true
to tno best of my knowledge and belief
Signed this day of , 10 , at
jj; I Atyn.lL,, VdllBlin/J
Subscribed and sworn to before mo this day of , 19.
[Slfnoluri q/offUlol odmtniUirtnt oaU\
c.a.4 —— —
RarlMd Julj IB. las »-"*» irufcl |/»««I/W|
Compensation Form C. A. 4
(Revised 7-19-27)
CLAIM FOR COMPENSATION ON ACCOUNT OF INJURY
Description Actual size 85 by 14 inches; 1 page, printed
face and reverse
Routing Original and two copies as follows; original and
first copy to Compensation Section; second copy retained
by local ednlnistrative office.
Instructions for ^Preparation See Operating rrooedure Ho. F-35.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
ATTENDING PHYSICIAN'S CERTIFICATE
(U any of tlio Information o«11cd (or below can not bo suppllod, tho physician should ontor on explanation undor " Remarks")
1. Nome of cmployoc .'or whom certificate U glvoo ......
2. Dato and hour of first treatment ; dolo of laot (roatmont
3. Number and dato* of treatments: (o) 0(11 eo
W llomc
(r) Hospital
4. Give exact statement of tho nature and extent of the disability for whloh treatment was sought
(o) X-ray findings.
(b) Laboratory findings
5. Did employee give you a history of injury as the cause of the disability? If so, stato It briefly.
6. Give briefly your opinion of the actual cause of the disability described abovo.
7. What other concurrent or complicating diseases or disabilities were present?.
8. (a) Nature of past treatment
(b) Operations performed
(c) Present treatment
(rf) Treatment recommended
9. Was the employee confined to bed? ... If so, how long? — .... ....
10. If not confined in bed, was he confined to his home? If so, how long? -
11. Did this disability prevent his working? If so, when did such disability begin? — —
|>tu( *or tUoblrtfor KOril
12. Date employee was sufficiently recovered to take up—(a) Usual occupation? (6) Any otner work?
13. How long, in your opinion, will total disability continue for—(a) Usual work? (6) Any other work?
14. How long, in your opinion, will partial disability continue for—(a) Usual work? (6) Any other work?
15. In your opinion, are any permanent results from his injury probable? If so, describe them In detail
16. Remarks
I hercbt certify that I am licensed to practice medicine and surgery In the state of
Signed this day of._ ..... 19 [aioiiiuYofartwii
CERTIFICATE OF OFFICIAL SUPERIOR OF INJURED EMPLOYEE
[Report of Injury (Form C. A. 2) if not heretofore forwarded Id the Commission, should accompany this claim.)
If any circumstances have arisen which alter the conclusions stated in the official report of injury (Form C. A. 2), or if the
official superior disagrees with any of tlie statements made in the claim for compensation, It is requested that a full explanatory
statement be under " Remarks."
1. If the injured employee is a pieceworker or an Irregular worker, what were his full earnings during the month Immediately pre¬
ceding the injury? S ; actual number of days employed —
I for nompIt. If ikj rmptofu i o)vt4 on ilu Tit of kit foil ion loot otouU (w flm lot 7 to /<(•««.» I. Iarlw!w|
2. Has employee resumed work? If so, give date and hour ......
3. Has employee been paid for any portion of the absence for which compensation is claimed? If so, state inclusive
dates —
4. Remarks.
I hereby cErnrr that the \erson who executed the foregoing claim for compensation was injured while in the performance of
his duty for the United States. An officlsl report of this Injury on Form C. A. 2 has beeo made, and all statements made In aald report
arc true to the best of my knowledge and belief.
Tai'ii'w. via'diirapiwrT"
SigDed this
Appendix B
Compensation C. A. 8
Face and Reverse
CLAIM FOR CONTINUANCE OF COMPENSATION ON
ACCOUNT OF DISABILITY
JSMat SiSKT *■
flll no.
fit A 1* I The OompanaaUon Act of September 7, IBIS, provldae that whoever rxunkee, In an/ olaUn toj
N|| 1 II It pompenanuon, an/ etatement, knowing It to bo falae, a hall be aulliy of perjury and ahall 6e pjmiahad
ll \J 1 IvL ta/»Sd*lmnrt£am«nt M.OOO, orb/ Imprtaonmont for net mote than ona /ear, or by both nub
19
(DbU of lb la Unlm)
U. S. Employees' Compensation Commission,
WaiKington, D. 0.
I herebt certipt that, on account of the injury sustained by me on , 19
partially lD*u <* Nary)
was Ltallv disabled from 1 , 19 , to , 19 , incluaive
and therefore request compensation for that period, in accordance with claim previously filed under the terme
of the Employeee' Compensation Act of September 7, 1916, as amended.
1. Have you worked during the period for which compensation is claimed on this form? ....
Note.—If your anrwer to the above qneeUon la "Fee," the following Information moat be furnished before eomeeaaatkn
can be paid. Statement of rale of pa/ and total earnings nut Include the raise of aabeietenco, quarters, or other advantage*
received aa part of pay. If claim covara more than one calendar month, report earnings for each month arparataly in the apace
provided on thla form.
(а) Dates on which employed
(б) Rate of pay, S ^ month ^ Total amount earned,* $
(d) Hours worked per day (c) Days worked per week
(/) Nature of work performed
(jj) Names and addressee of employers
• Following ipace to be used If claim covers more than one calendar month.
Month and year
Amount mitred
Nature of work partormod
Nam. and addnm at amptsyw
1
2. If only partially disabled and you have performed no work, state why you have not worked:
3. If you have endeavored to find work, give names and addresses flf persons from whom you sought work
4. Are you receiving from the United States a pension, compensation, or other allowance of any kind on
account of military service? . _ If so, state (a) amount received per month,
(ft) nature nf award
(Snob u retired pay, rerrlts panaku, nocrerrloB eoanaetad dire bill ty allowtnoa, tie.)
(e) Veterans Administration claim number
6. Are you receiving from any State, county, or municipality, or from any private relief organisation
any penaion or allowance? If so, state full particulars
I hereby certipy that every statement aa set forth above in.support of my claim ig true and correct to
the best of my knowledge and belief.
(Nun. of claimant)
Date of this certificate , 19....
(Addreaa)
Certificate on back of Uda farm must be eiecnted by attending phyaiclaa sad official auyai lui.
C.A.S „ n
Borland Jun. ». 1BZ3
Compensation Foraj.C. A< 8
(Revised 6-25-S2)
CLAIM FCR CONTINUANCE OF COMPENSATION
ON ACCOUNT OF DISABILITY
Desoription Actual sice 8^ by 14 inches j one page, printed
faoe and reverse.
Routing Original and two oopies as follows-, original azvi
First oopy to Compensation Seotion; seoond oopy retailed
by local administrative office.
Instructions for Preparation See Operating Procedure No. F-35.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
CERTIFICATE OF ATTENDING PHYSICIAN
I, the undersigned, a duly licensed practitioner of medioino and surgery, do hereby certify that I hare
been disabled from ........ . to t Inclusive, the
following is a report of my findings based upon this examination.
1. Nature of disability
2. Is this condition due to the injury for which compensation is claimed? ..
3. What treatment is recommended to hasten recovery?
4. Is such treatment being given? If so, by whom? .
5. Is claimant in hospital? If so, state dato entered and probable period of hospitaliza-
6. Is claimant confined to bed?
7. If claimant has been discharged from further treatment, give d
8- Is disability total for usual work? If not, estimate percentage in terms of
function per cent.
9. How long, in your opinion, will such disability continue?
10. Is claimant, in your opinion, able to perform other work? If so, what
"kind?
11. Prognosis
12. Comment or recommendations
Date of this certificate , 19
CERTIFICATE OF EMPLOYEE'S OFFICIAL SUPERIOR
Has claimant received any pay, subsistence, or quarters from your establishment for any portion of
period during which compensation is claimed on this form? — . If bo, give dates for which paid
or for which subsistence or quarters were furnished and the value thereof
Is the claimant, in your opinion, disabled for his usual occupation?
It the claimant, in your opinion, able to perform other work of a remunerative character?
If so, describe kind of work: — —
Dste of this certificate, , 19
Note. —OSclal snperlors are urged to examine this fern whoa ii is presented br (he claimant and to ana that all qnaalloaa
oa the reverse of the torn are answered. Carofal observance of this procedure will eipedlte action upon the claims and redoes
correspondence in connection therewith.
Appendix B
Special Compensation C. A. 16
Face and Reverse
REQUEST FOR TREATMENT OF INJURED EMPLOYEES OF THE
WORKS PROGRESS ADMINISTRATION
Employees of the Works Progress Administration will bo provided with medical, surgical, and hospital
treatment only for traumatic injuries sustained in the performance of duty. This request for treatment
authorizes the physician or hospital addressed to furnish treatment only if the condition presented may reason¬
ably be attributed to the traumatic injury described below. Traumatic injury is defined as "injury by
accident causing damage or harm to the physical structure of the body and shall not include a disease in any
form except as it shall naturally result from the injury."
, 19..
(DaU)
To
(Nuna of hospital or physician) (Address)
The bearer, Age Sex Color
(Full name of Injured employee)
is an employee of the Works Progress Administration employed as
(Name of office, establishment, or project where employed) (Location)
He was injured in the performance of duty on , 19
(Date)
Nature of injury for which treatment is authorized
Treatment is requested for the direct results of said injury.
Reasonable fees for services rendered by private facilities pursuant to this request will be paid by the
United States Employees' Compensation Commission upon presentation of charges therefor prepared on
Form S-69. Medical jeeswill be -paid at rates not in excess oj the minimum charges prevailing in the community
jor similar services. Hospital charges will be allowed only at rates for ward service, except where use of a
private room is absolutely necessary because of the patient's condition.
Hospital and physician charges, the latter accompanied by a current medical report of the case should
be submitted at the termination of treatment or monthly.
(Slgnaturo of offlaUl superior)
(Title of official position) "
(Address) l9—1Ma
(The report on the beck of thla form to be completed by phyrtden)
Special Compensation Form C. A. 16
(Revised 7-16-35)
REQUEST FOR TREATMENT OF INJURED EMPLOYEES OF
THE WORKS PROGRESS ADMINISTRATION
Description Actual size 8 by IO2 inchesj one page, printed face
arid" reverse.
Routing Original and one copy as follows: original to dootor
or~Txospitalj copy to Compensation Section.
Instructions for Preparation See Operating Procedure No. F-35.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
PHYSICIAN'S REPORT
U. S. EMPLOYEES' COMPENSATION COMMISSION
WASHINGTON. D. C.
1. Name of patient Age Sex
2. Home address of patient
3. Place of employment
4. Date and hour of your first treatment
5. Case history as stated by patient. Give date of accident
6. Give nature and extent of injury as found on your first examination and state your objective findings:
7. Is condition complained of due to accident described by patient?
8. Is this accident the only cause of disabflifly? i If not, state contributing causes
9. Has patient any physical impairment due to previous injury or disease? If so, describe
10. X-ray-laboratory-specialists' reports
11. Describe treatment given by you
12. Was patient hospitalized? Name of hospital
13. Date admitted to hospital If discharged, give date
14. Is further treatment needed? For bow long?
15. Will injury cause any permanent disability? If so, what?
16. Patient
was
, 19
may be
17. Patient
was
may be
19
18. If death ensued, give date
19. Number of treatments given by you at (1) office , (2) home .. , (3) hospital
20. Remarks (give any information of value not included above):
I hereby certify I am a duly licensed physician in the State of
and was graduated from Medical School in the year
Date of this report
(Nana)
Uddnii)
NOTE—OOdal o—orWo n*Ml Cor ft—It— or tr—t—« (Em CA-ll or CA-17) moot ocoompooy roaekor for modkal oatrlcoo.
w. i. Mtiuair miiiih orrici 10—1M>
Appendix B
Special Compensation C. A* 17
Pace and Reverse
ffpeolal Form C. ▲. IT
REQUEST FOR EXAMINATION OF WORKS PROGRESS ADMINISTRATION
EMPLOYEE WHEN CLAIM IS IN DOUBT
Employees of the Works Progress Administration will be provided with medical, surgical, and hospital
treatment only for traumatic injuries sustained while in the performance of duty. Traumatic injury is defined
as "injury by accident causing damage or harm to the physical structure of the body and shall not include a
disease in any form except as it shall naturally result from the injury."
193
To
(Name of phyildan) (Address)
The bearer, Age Sex Color .
(Pull nam* of Injurad employ*)
is an employee of the Works Progress Administration, employed as
(Occupation)
at
(Nemo of office, establishment, or projoct where employed) (Location)
There are reasons to believe that he may have been injured in the performance of duty on
193 The alleged injury is claimed to be due to
(Cause of Injury claimed)
The resulting disability appears to be
(Nature of disability)
You are requested to examine the employee and advise this office at once whether in your opinion the
disability is due to the alleged injury described above. If there seems reason to believe the disability may
be due to accident alleged, treatment should be rendered Jfor the direct result of the accident until it can be
definitely ascertained whether the case is one for which treatment should be continued under the regulations.
If, in your opinion, the condition for which treatment is sought is not due to the alleged accident no
treatment should be furnished on this request but report of examination should be furnished this office
immediately.
Reasonable fees for services rendered pursuant to this request will be paid by the United States Employees'
Compensation Commission upon presentation of charges therefor prepared on Form S-69. Medical fees
will be paid at rates not in excess of the minimum charges prevailing in the community for similar services.
(Signature of official superior)
(Title or official position)
(Address)
(Report on back of thla form to ba completed by examining phyalclan)
Special Compensation Form C. A. 17
REQUEST FOR EXAMINATION OF WORKS PROGRESS ADMINISTRATION
EMPLOYEE WHEN CLAIM IS IN DOUBT
Description Actual size 8 by 10j| inches; 1 page, printed face
and reverse.
Routing Original and one copy as follows: original to doctor
or""hospital; copy to Compensation Section,
Instructions for Preparation See Operating Procedure No, F-35.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C,
PHYSICIAN'S REPORT
U. S. EMPLOYEES' COMPENSATION COMMISSION
WASHINGTON. D. C.
1. Name of patient Age Sex
2. Home address of patient
3. Place of employment
4. Date of examination
5. Case history as stated by patient. Givo date of accident
G. Give nature and extent of injury as found on your first examination and state your objective findings
7. Is condition complained of duo to accident described by patient?
S. Give reasons briefly for answer
9. Is this accident the only cause of disability? If not, state contributing causo
10. Has patient any physical impairment due to previous injury or disease? If so, describe
11. X-ray—laboratory—specialists' reports
12. If treatment given by you, describe
13. TTas patient hospitalized? Name of hospital
14. Date admitted to hospital If discharged, give date
15. Patient j ^ J able to resume regular work
16. Patient j may be)a^'e *° rcsume work
17. Remarks: (Give any information of value not included above)
I hereby certify that I am a duly licensed physician in the State of
and was graduated from ....... ........ Medical School in
the year
Date of this report
(Signed)
(Nam*)
(Address)
NOTE.—Official auparior'a rorjueat for examination (Form C. A.-17) muat accompany vouchar for aarvtcoa randarad.
Appendix B
Compensation K-l
compensation
FORM K-1 WORKS PROGRE88 ADMINISTRATION
SHORT FORM OF ACCIDENT REPORT
works Progress Administration of
(to be prepared at once for every minor accident,
namely, an accident where it appears probable
that there will be no lost time nor treatment
beyono first aid, and to be signeo roth by the
injured man and by his official superior)
193
TO T E WORKS PROGRESS ADMINISTRATION
CO' PENSAT I ON OFFICER
I REPORT THAT (NAME) (NUMBER.) ( OCCUPATIOfj)
(Address)
Was accidentally injured in
the performance of duty on project no
and received first aid, as follows:
Name of First aid Man
The accioent happened as follows:
The injury is:
Witnesses to above accident:
Name Aqdress
Name a doress
The above injury is reported sy me in accordance with Regulations and the foregoing state¬
ments are true.
subscri bed
(Injured Employee)
Superintendent, Foreman, Timekeeper, Injury Clerk
One copy of this report must be made out and forwarded immediately to the local office of the
Works progress administration, where it will be held penoing instructions from State Compensa¬
tion Officer as to final disposition.
Compensation Form K-l
SHORT FORM OF ACCIDENT REPORT
Description Actual size 8 by 10^ inches; one page, faoe
onTy^
Routing Original and one copy as follows: original to
Compensation Section; copy retained cm projeot.
Instructions for Preparation See Operating Procedure No,
F-35 .
Form to be duplicated by State Works Progress Admin¬
istration.
a ;M .
193 a t p.m.
Appendix B
Compensation S-69
Original and Memorandum
"""" N°'""" Public Voucher for Services and Supplies of
Hospitals and Physicians
U. S. EMPLOYEES' COMPENSATION COMMISSION
Thin voucher in to be forwarded to the U. S. Employee*' Compensation Commission, Washington, D. C.,
and MUST be accompanied by the original request for treatment (unless latter has been previously forwarded
to the Commission). If original request for treatment has previously been forwarded to the Commission, note
such fact with date. r_
Appropriation: "Employees' Compensation Fund"
THE UNITED STATES, Dr., To..
Address
(For use of Paying Office)
(Bteeot)
(City)
(State)
Please follow as carefully as possible the following instructions:
1. Description of injury treated. (Please state diagnosis as exactly as possible).
2. Character of services or supplies furnished. (Please explain fully reason for any differences in charges on different dates, ■
itemise bills for supplies.)
3. Exact dates of treatment and charges made for every treatment.
(AN UNITEMIZED BILL CAN NOT BE PAID)
Contract No. .
Date or
period of
treatment
UNIT PRICB
, _>nd lust, that
Ihixefor h», not been r««iTed, andtfut if a |>1
vai not during tha abota period a full-lime employ*. of
■be United Statu.
CERTIFICATE OF INJURED EMPLOYEE
I certify (hat tlio obove-mentlonod services and /or suppllos were received by me, and that
I havo not paid any portion of the charges therefor.
(Sign Original only)
(Payee will NOT u
Differences:
(Sign original only)
Account verified; correct
| (Signature or initials)
For Administrative Certificate, see Form S—92.
Paid by Check No..
dated , for $..
f.nTr
- \ In fa«
i oj tha IJnltad Stataa
•When a voucher Is signed or receipted In the name of a company or corporation, the name of the person writing the company or corporate name as
which be signs, must appear. For example: "John Doe Company, per John Smith, member of firm," or "Secretary," or "Treasurer," as the ease may tx
well as the capacity In
Compensation Form S-69
PUBLIC VOUCHER FOR SERVICES AND SUPPLIES
OF HOSPITALS AND PHYSICIANS
Description Actual size; original 8 by lOjg- inches, memo¬
randum 8 by 13^ inchesj printed faoe only.
Routing Original and memorandum and one copy of original
and memorandum to Compensation Section.
Instructions for Preparation See Operating Procedure No. F-35.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. Ce
oJSCSKIift . Public Voucher for Service, and Supplies of
w",r•"*' Hospital, and Phyrician.
U. S. EMPLOYEES' COMPENSATION COMMISSION
This voucher ii to be forwarded to the U. S. Employees' Compensation Commission, Washington, D. C.,
and MUST be accompanied by the original request for treatment (unless latter has been previously forwarded
to the Commission). If original request for treatment has previously been forwarded to the Commission, note
such fact with date.
Appropriation: "Employees' Compensation Fund"
THE UNITED STATES, Dr., To
(Payee)
Address
(Street) (City) (State)
Please follow as carefully as possible the following instructions:
1. Description of injury treated. (Please state diagnosis as exactly as possible).
2. Character of services or supplies furnished. (Please explain fully reason for any differences in charges on different dates, and
itemise bills for supplies.)
3. Exact dates of treatment and charges made for every treatment.
(AN UN ITEMIZED BILL CAN NOT BE PAID)
Voucher No
PAID BY
(for uso of Paying Offlc«)
Contract No Date
Paid by Check No , dated. for t (ZZZZZZZOZZZ"
* When a voucher Is signed or receipted In the name of a company or corporation, the name of the person writing the company or corporate name, as woil aa the capacity In
which be tfgns, must appear. For example: "John Doe Company, par John Bmlth, member of firm," or "Secretary," or "Treasurer," aa the case may be. a— nsa
U. S. EMPLOYEES' COMPENSATION COMMISSION
OFFICE OF THE CHIEF OF ACCOUNTS
Sib:
The inclosed check, No.-.
for payment of the account described in the attached memorandum.
No acknowledgment of receipt of check is necessary.
Respectfully,
memorandum
Not*.—If the payee named in the
attached voucher will supply below
auch data as will identify the check
drawn in payment thereof with tho
account in his office, this slip will be
mailed with the check.
settles voucher submitted —
Chief of Account*.
APPENDIX B
STANDARD FORMS
Appendix B
Standard 1012
Faoe, Center and Reverse
Standard Form No. lOlJ-Rtrlnd
Form Approved bt
comptroller General, D. B.
July 19, 1ST
General RogulaUone No. M
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT D. 0. v™. No.
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL Bureau No
FOR PER DIEM in lieu of subsistence, mileage for personally owned motor vehicle, and/or REIMBURSEMENT
of travel and other expenses paid by me in the discharge of official duty from , 19 ,
Dollars Cams
to 19 , as per itemised statement within, under authority No
19 , copy of which is attached,* or has been previously furnished with voucher No
19 by
(Nuns of disbursing officer)
., dated..
paid
I do solemnly swear (or affirm) that the above account and schedule
annexed are just and true in all respects; that payment therefor has not been
received; and that my statement of travel performed upon transportation
requests and/or by motor vehicle correctly reflects travel performed by me on
official business.
SICN Payee™
ORIGINAL
ONLY Ttt.ln
(Pay** will NOT un thU ipau)
Differences—
Account verified correct for $
(Signature or initials)
Subscribed and sworn to (or affirmed) before me at this day of ..
Title
19_
Recommended for approval:
(To be uied at discretion of department, bureau, or establishment)
(Immediate supervising official)
I certify that the official headquarters, domicile, or residence of the claimant is as stated above; that the travel was authorized from
and to the points stated in the account, and for the period and at the subsistence rate or rates claimed, as Bhown by the authority on
file, or (if such authority was not issued in advance of travel) as satisfactorily explained and approved hereon as required bv the Stand¬
ardized Government Travel Regulations; that the within itemized statement including claimant's statement of travel performed upon
transportation requests has been examined and is certified correct, except as noted; and that the amounts therein claimed are just and
reasonable, except as noted.
fApproved for $...
SIGN
ORIGINAL
ONLY
ACCOUNTING CLASSIFICATION (For completion by administrative offlor)
Armor button , Limitation
ob Project Symbol
Appropriation Title
Limitation ob Pbojbct
Appropriation
Amount
Amount
$
Allotment Symbol
Amount
Encumbrance
Liquidated
Cobt Acts
dunt
Object or Extendituee
Symbol
Amount
Symbol
Amount
$
$
f Check No...
Paid by |
I Cash, $.
, dated , 19 , for
, 19...
SICN
ORIGINAL
ONLY
J on Treasurer of the United States
I in favor of payee named above.
(Signature of payee)
•If there was no prior authority itata drenmstonoea which rendered eecurlng prior authority impracticable.
tlf the ability to certify and authority to approve are oombtned In one person one ilgnatare only ■ neoeaaary; otherwise the approving offioa
"Approved for f and over bl» official title.
Standard Form Noe 1012
(Revised 7-19-37)
VOUCHER FOR PER DIEM AMD/OR REIMBURSEMENT
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL
Description Aotual site 8 by 21 inches; 1 page, folded, printed
faoe, oenter and reverse.
Routing Original only, to Treasury State Aooounte Offioe.
instructions for Preparation See Operating Prooedure No. F-20.
Printed form supplied on request by Works Progress Adminis¬
tration. Washington, D. C.
57212 0—38 13
ITEMIZED SCHEDULE OF TRAVEL AND OTHER EXPENSES
1. Date and hour of departure from official headquarters
2. Give duty status on first day of voucher period: <DmU) <Hoar)
•Arrived at on , 19 ,
for temporary duty for approximate period
Approximate date of return to official headquarters , 19
4. fState authorized allowance for actual subsistence expenses: Not to exceed $ per day.
5. Where for traveler's personal convenience or through the taking of leave there is interruption of travel, deviation
from the direot route, or where traveler delays at a place other than post of duty, a statement showing the facte
should appear on the voucher.
•If authority provide* lor travel to more than one point, time of arrival and departuro (Km each ahould be atatod In the body of the account In obronologloal order,
fIf more than one rata of allowance la aothortaod, foil atatemant of application of each rata muat be given In aome convenient place on thle voucher.
DAT*
IS
CHARACTER OF EXPENDITURE
(To be Itemised by the day and fully explained)
SUB-
VOU.
NO."
AMOUNT
NOTATIONS
BUBOSTZNCg
Othis
(Payee must not
use this oolumn)
Total amount op voucher (not to be used when totals are carried forward to continuation sheet)
••Whan sub vouchers required by regulations were not obtained, elate folly the dreamstanoee showing reason lor omission.
to-ioee
STATEMENT OF TRAVEL PERFORMED FOR WHICH REIMBURSEMENT IS NOT CLAIMED
BY TRAVELER
DATE OF
TRAVEL
NO. OF TRANS¬
PORTATION
REQUEST OR
SPEEDOMETER
RXADINO
FROM-
TO-
VIA
(Kind of carrier
or vehicle)*
GLASS OR
MILEAOEt
AMOUNT
•Railroad, • teams hip, airplane, bus. etc.
fAbbrevlato class of service or accommodations used. Railroad: F, first claes; I, intennodlato class; M, mixed clan; C.oosch; P. Pullman accommodations; DR, drawing room;
OP, compartment; BR, bodroom; SOS, flnglo occupancy section; SBO, section; LB, lower berth; UB, upper berth; 8, seat. By other mode: Number o( miles traveled.
INSTRUCTIONS
1. The provisions of the travel regulations must be strictly observed in order to avoid suspensions and disallowances in the accounts.
2. When more space is required for itemization of the account, use continuation sheets (standard forms 1012b—Revised and
1012c—Revised) and fasten together in upper left-hand corner.
3. As many copies of the approved memorandum voucher may be made as required for administrative purposes.
Appendix B
Standard 1012a
Faoe, Center and Reverse
Btandaia Form No. 101«a—B
roan ArraoriD it
Court mo mm Ouuil, U. I.
July IB, 1017
Oouarml Itafolmtloni No. U
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT d o Vou No
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL Bureau No
•I aetata* mat W ciwplihdy fiflad In by peyoa priar to alfaatwe, and than anrf nal ba any arania w akaratian unburn faddabd m ai|nad by has)
PREAUDIT
Oartlflod tor payment In the
tub Dxtrd State
u. s
(Department, bureau, or eatabllihment)
THE UNITED STATES, Dr., To
(Payee)
(Addrem)
Official Headquarters.
Domicile Residence _
(For dm of Postal Serrloe only)
FOR PER DIEM in lieu of subsistence, mileage for personally owned motor vehicle, and/or REIMBURSEMENT
of travel and other expenses paid by me In the discharge of official duty from 19 ,
to , 19 , as per Itemised statement within, under authority No dated ,
19 , eopy of which is attached,* or has been previously furnished with voucher No paid ,
19 , by I
(Noma of dlsbnitlni officer) .
(P>r»a will NOT u
Differences-
Account verified correct for S
(Signature or initials)-
MEMORANDUM
ACCOUNTING CLASSIFICATION (Tor a
LnaTATtOR os Psorscr
Cost Aoooukt
Obtsct or ExronuTumx
Paid by
1 Hash, 9
SIGN
ORIGINAL
Ion Treasurer of the United States
in favor of payee named above.
"m-T (Mfnatora of payaa)
metered wcurinf prior authority lmpraotlaable
Standard Form .No* 1012a
(Revified 7-19-37)
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL
(Memorandum)
Description Aotual sise 8 by 21 inches; 1 page, folded, printed
faoe, oenter and reverse.
Pouting Pour copies, to be prepared with Standard Form No. 1012
Revised; first and seoond oopies to Treasury State Aooounts
Offioe; third copy to Division of Finance; fourth copy retained
by traveler.
Instructions for Preparation See Operating Prooedure No. F-20.
Printed form supplied on request by Works Progress. Adminis¬
tration, Washington, D. C.
ITEMIZED SCHEDULE OP TRAVEL AND OTHER EXPENSES
1. Date and hour of departure from oliioial headquarters
~2. Give duty status on first day of voucher period: <DbU) (Uour)
•Arrived at on , 19 ,
for temporary duty for approximate period •
Approximate date of return to official headquarters , 19
4. fState authorized allowance for actual subsistence expenses: Not to exceed $ per day.
5. Where for traveler's personal convenience or through the taking of leave there is interruption of travel, deviation
from the direct route, or where traveler delays at a plaoo other than post of duty, a statement showing the facts
should appear on the voucher.
notations
Totals (to be carried forward to continuation sheet, if necessary)
Total amount or vouch eh (not to be used when totals are carried forward to continuation sheet)
"Wben sobvoucbers required by regulations were not obtained, state fully the dr aims lances showing reason for omission
STATEMENT OF TRAVEL PERFORMED FOR WHICH REIMBURSEMENT IS NOT CLAIMED
BY TRAVELER
DATE OF
TRAVEL
NO. OF TRANS¬
PORTATION
RBQUEBT OR
SPEEDOMETER
READING
FROM-
TO—
VIA
(Kind of carrier
at ▼ahlcla)*
CLASS OR
MILEAOKt
AMOUNT
•Railroad, itsamahm, airplane, bui, etc
f Abbreviateclaa ofserviceor aocomnlodatloM toed. Railroad: F. first data; L Intermediate dan; M, mixed din; O, coach; P. Pullman accommodation*; DR. drawinc room;
•P, oompartment; BR. bedroom; 80S, tingle occupancy aectlon; 8SO, lection; LB, lower berth; UB, upper berth; 8, (eat. By other mode; Number of mllai traveled.
INSTRUCTIONS
1. The provisions of the travel regulations must be rtrictly observed in order to avoid suspensions and disallowanoee in the accounts.
2. When more space is required for Itemization of the account, use continuation sheets (standard forms 1012b—Revised and
1012o—Revised) and fasten together in upper left-hand corner.
3. As many copies of the approved memorandum voucher may be made as required for administrative purposes.
Appendix B
Standard 1012b
Faoe and Reveree
Standard Form No. lOUb-nnlad
Form approved by
Comptroller Oenval V. I.
QtamtX Retuletlomi No. IS
Voucher for Per Diem and/or Reimbursement of Expenses Incident to Official Travel
CONTINUATION SHEET
Payee
ITEMIZED SCHEDULE OF TRAVEL AND OTHER EXPENSES
DATE
10....
CHARACTER OF EXPENDITURE
(To bo itemized by the day and fullv explained)
Sub-
AMOUNT
NOTATIONS
°""b"
Subsistence
Ottieb
(Payee most not
use this column)
—
10— 1044b
Standard Form No. 1012b
(Revised 7-19-37)
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT
OF EXPENSES INCIDENT TO OFFICIAL TRAVEL
(Continuation Sheet)
Description Actual site 8 by 10& inchesj 1 page, printed face
and reverse.
Routing Original only (prepared when neoessary to accompany
Standard Form No. 1012 Revised, to Treasury State Accounts
Offioe.
Instructions for Preparation See Operating Procedure No. F-20.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
DATK
CUARAOTKR OF EXPENDITURE
Bub-
AMOUNT
NOTATIONS
M-...
(To bo Itomliod by tbo day and billy explained)
number
BunsisTiNOB
Oman
(Payoo munt not
uso this column)
1
1
1
|
'
1
! ~~
i
i
i
i
1
i
!
1
i
i
1
I
Total amount or ▼occHza (not to be used when totals are carried forward to Continuation Sheet) —
" ~ ~
Appendix B
Standard 1012c
Face and Reverse
Standard Form No. lOlBo—BavlMd
Farm appro-rod by
Comptroller Oanl, U- 8.
July 18,18J7
O«o—1 BnuUUon* No. ■
Voucher for Per Diem and/or Reimbursement of
Eapones Incident to Official Travel
CONTINUATION SHEET
MEflWDMMIMIRl
Payee ..
ITEMIZED SCHEDULE OF TRAVEL AND OTHER EXPENSES
DATE
CHARACTER OF EXPENDITURE
(To bo ltamlnd by the day end fully oxplalned)
8ub-
AMOUNT
NOTATIONS
Dumboi
BuaalBTBJICB
OTHBH
(Payao muat not
uae tblo column)
—•
—
Standard Form No, 1012c
(Revised 7-19-37)
VOUCHER FOR PER DIEM AND/OR REIMBURSEMENT
OF EXPENSES INCIDENT TO OFFICIAJT TRAVEL
(Memorandum Continuation Sheet)
Description Actual else>8 by">10|- inches; 1 pag^, printed face
~ and reverse.
Routing Four copies, -to be prepared with Standard Form No.
lt)12b Revised; .first and second copies to Treasury State
Accounts Office; third copy to Division of Finance; fourth
copy retained by traveler.
Instructions for Preparation See Operating Procedure No. F-20.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
DATE
It....
CHARACTER OF EXPENDITURE
(To bo llomlaod by tbo doy ond fully oipltluod)
Bub-
AMOUNT
NOTATIONS
Dumber
HUlllMTaNCB
Orn»
(Poyeo muit not
uao thli ooliimn)
i
—
i
T
otal o mount op voucher (not to be ueed when to tela ere carried forward to Continuation Sheet)
U>—1644 •
Appendix B
Standard 1012e
Subvouoher No. .
STATEMENT OF TRAVEL BY MOTOR VEHICLE
(Submit In duplicate with reimbursement account)
standard Worm loile
7arm approved *~
Oomptralbr "
(Department or Ertal
(Nam* of traveler)
(Bureau or Offlea)
Statement of travel accomplished with registered at
(Automobile or motoroycla)
owned by ....
(Pbaa) (Registration number)
and operated under letter of authorization number dated .
(Name of owner)
Period from .
to
Din
BrrwiKM What Points
Houm or
DarABTOBB
hovb of
Akbival
Mbtbb Rbadixcm
MOBB
Tbav-
blbd
Ratb
PbA
Mils
Amount
Claimed
From—
To—
A.M.
P.M.
A.M.
P M.
Start
End
Grnti
Total,
I hereby certify that the travel indicated above was officially necessary; that the information given is
correct; that no part of the travel for which compensation is claimed was performed within the corporate
limits of my official station.
(Slgnatnra of traveler)
Standard Form No. 1012e
STATEMENT OF TRAVEL BY MOTOR VEHICLE
Description Aotual size 8 by lojjr inches; 1 page, printed face
only.
Routing Original and four copies, prepared when neoe6sary to
accompany Standard Form No. 1012 Revised; original and first
and second copies to Treasury State Accounts Office; third
copy to Division of Finance; fourth copy retained by traveler.
Instructions for Preparation See Operating Procedure No. F-20.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D.C.
Appendix B
Standard 1013
Pace and Reverse
IB Amon^i'coMiwLw'l?uiiiil U. i
PAY ROLL FOR PERSONAL SERVICES
AMFLOVIU ON ANNUAL SALARY BASIS)
We, the eubeoribera, severally acknowledge to have received of the above-named disbursing officer, IN CASH, the sums set opp
respective names in payment for our services during the period of this pay roll, except as noted in the column of "Remarks", and we here!
that said sums are correct:
osite our
>y certify
Biomatubes fob Cass and Nota¬
tions or Chuck Patmsnts
(number and date)
»tm a
trc
irar*"-
Standard Form So. 1013
(Reviaed 5-19-37)
PAT ROLL FOR PERSONAL SERVICES
(EMPLOYEES ON ANHTJAL SALARY BASIS)
Deaorlptlon Aotual sis* 11 by 17 Inchesj 1 ps^e, printed faoe
and reverse.
Routing Original only, to Treasury State Accounts Offloe.
Instructions for Preparation See Operating Prooedure Ho. F-6.
Printed form supplied on request by Works Progrose Adminis¬
tration, Washington, D. C.
D. O. Vou. Xo.
PAY ROLL FOR PERSONAL SERVICES
(EMPLOYERS ON ANNUAL SALARY BASIS)
Department or Estaburiiurnt
Bureau or Sbryicr
Location
Period from to .
priations)...
NOTATIONS
'Pursuant to authority vested Id ma I certify that the within pay
roll. In — pages, 1* correct; that it appears from the record* of my
offioe that the person* named thereon were lawfully appointed; that
each ha* performed, under my supervision, the servioea indicated by
the respective, proper official designation or occupation during the
period mentioned, except a* otherwise indicated In the oolumn of
''Remark*"; that payment therefor ha* not previously been made: that
no person whose name appears on the within par roll Is being paid for
any period of absence in excess of that allowed by law, or Is reoeiving
'ruble compensation prohibited by law, *" **- ' 'J "
Aooount verified; correct for...
(Signature q
ACCOUNTING CLASSIFICATION (Far csmplsMss by AdalalstrmllTS Office)
R PROJECT SYMBOL
LIMITATION OR
PROJECT AMOUNT
APPROPRIATION
COST ACCOUNT
SYMBOL AMOUNT
OBJECT OP R
ATM SOL AMOUNT
*f>*w'lh«''sM>»S'S>TltswSsSM»«asrlwiiitoe1>d|iSlt»swwSltilMin
spsaiSseensi mtt N —wT. sttMstis tts sgmsvlssShe HISp la ih Mssfc see Mw1
'"Assistedfar I ".a
Appendix B
Standard 1013a
>-!KSK{!Bi2Sr«SBUa PAY ROLL FOR PERSONAL SERVICES
■ MuV IW1 (IMPLOYEEf ON ANNUAL SALARY BASIS)
<Ne. R«. No. M, Sup No. i OONTIN CATION EDSST
m aaubUobmaal) (Soma, dltUiaa, o* oOa) (loeMHol
Period from 193...., to 193_..
(Nudo tad daAfiuUao of dtalnnlot oOta»
We, the lubecriben, severally acknowledge to hove received of the above-named disbursing officer, IN CASH, the sums aet opposite our
respective names in payment for our services during the period of this pay roll, except as noted in the column of "Remarks", and we hereby certify
that said sums are oorreot:
No.
N ami, Qiaos, Diaiqnatiom, and
Total Balaiy Rati
Oioas
Amount
Eainid
Diduotioks
Nit
Amount
Paid
SioNATuue vol Cash and Nota¬
tions or Chick Patmshti
(Dumber sod date)
TM.JI. NOT L b. Art M llMlll lll — Ut
Utrtr *"atm*
Retlie-
Other
1
a
a
4
6
0
7
8
e
10
n
12
13
14
15
16
17
18
ie
20
21
22
24
20
20
27
28
20
30
a
S
8
»
Standard Form No. 1015a
(Revised 6-19-57)
PAY ROIL FOR PERSONAL SERVICES
(EMPLOYEES ON ANNUAL SALARY BASIS)
Continuation Sheet
Description Actual site 11 by 17 inohoej 1 page, printed
face and reverse same.
Routing Original only (to be prepared when necessary to ac¬
company Standard Form No. 1013 Revised), to Treaeury
State Aooounte Offloe.
Inatruotions for Preparation See
Operating Prooedure No. F-6.
est by Works Progress Admin-
Printed form supplied on requ
titration, Washington, D. C.
Appendix B
Standard 1013b
Face and Reverse
....X^SSSiVJZ-SSSiuv i PAY ROLL FOR PERSONAL SERVICES p'°" N°
Out. II*. Wo'No. ■ (KMFLOYKU ON ANNUAL SALARY BASIS)
Period from . 103 , lo , 193
(Nona and d*i(n*lloo o1 dloboralaj
MEMORANDUM
No.
Nua, OnAD«, Designation, and
Total Balabt Rati
Obou
Amount
Deductions
Net
Amount
Paid
MEMORANDUM
Do Not Sion
Retlre-
Other
1
2
a
4
5
0
7
8
e
10
11
12
13
14
16
16
17
18
10
20
21
22
23
24
25
26
27
28
29
80
3
$
$
S
013b
(Revised 5-19-37)
PAY ROLL FOR PERSONAL SERVICES
(EMPLOYEES ON ANNUAL SALARY BASIS)
Memorandum
Description Actual site 11 by 17 inches; 1 page, printed face
and reverse.
Routing rour oopies, to be prepared together with Standard Form
No. 1013 Revised: first and fourth oopies to Treasury State
Accounts Office; second oopy to Division of Finance and
Accounts, Washington, D. C.; third copy retained by State
Division of Finanoe.
Instructions for Preparation See Operating Procedure No. F-o.
Printed form supplied on request by Works Progress Adminis¬
tration, 'Washington, D. C.
D. 0. Vou. Mo. .
Bu. Mo
PAY ROLL FOR PERSONAL SERVICES
dMPLOYm ON ANNUAL SALARY BASIS)
MEMORANDUM
Department oa Establishment
Bureau oa Service
Location
Period from to .
notations
Account rerlBed; correct for.
(Bithsturo or IniUsli)
MEMORANDUM
ACCOUNTING CLASSIFICATION (For completion bj Administrative OOce)
APPBOPBIATION. UMITtnON
OB PSOIBCT S1M-.OL
APPBOPB1ATTON TTTLB
symbol amount
symbol amount symbol
Appendix B
Standard 1013c
.ZXXSVSSX'JZK.&...» PAY ROLL FOR PERSONAL SERVICES P„.N.
On. nilMo!VTup. No. i (EMPLOYEES ON ANNUAL. SALARY BASIS)
CONTINUATION SHEET
(DafaHtan^'aiuibiiiibmaDi) Va^7^ruim,'aioiimi (LooUtonj
Poriod from , 193...., to , 193—
(Nun* tad dalfntUon ol dlabtsUm offlotr)
MEMORANDUM
Deduction!
Rem abes
1l&agfe:
No.
Name, Qbadb, Designation, and
Total Balabt Rate
Qbow
Amount
Eabnsd
Ratiie-
Other
Net
Amount
Paid
MEMORANDUM
Do Not Sion
$
•
•
9
PAY ROLL FOR PERSONAL SERVICES
(EMPLOYEES ON ANNUAL SALARY BASIS)
Description Actual site 11 by 17 inches; 1 page, printed
face and reverse same.
Routing Four copies, to be prepared together with Standard
form No. 1013a Revised: first and fourth copies to
Treasury State Aocounts Office; second copy to Division
of Finanoe and Aocounts, Washington, D. C.; third copy
retained by State Division of Finance.
Instructions for Preparation See Operating Procedure No. F-6.
IS
Printed form supplied on request by Works Progress Adrain-
ao
10-WU.
Appendix B
Standard 1030
Pace and Reveroe
WORKS PROGRESS ADMINISTRATION. WASHINOTON. P. C.
am/7tm<mu 0r.S*/virrJ
,/5> TlIK United States ofAmehiga
WPA-306. 55
_ fompan y fa Si//7tt. s A
f. \mmf ✓AmW«y
jIm*.*,- i
/ v / /trrsotLS /
'h
mm
I
/SipiimlMrr mftsnMr/rrS
jV07Z'-fe>lisn/' sf?irt(y inxbr/rfiotts rm rrvrri* Arm>/~
Standard Form No. 1030
GOVERNMENT REQUEST FOR TRANSPORTATION
Description Aotual site 7-3/8 by 3-1/8 inohes; 1 page, printed
face and reverse.
Routing Original only, to oommon carrier.
Instructions for Preparation See Operating Frooedure No. F-20.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
. -! ° si 3
351 ijt i
I = 1-3
i*5!!
« -5 J! c t
II =£ I
£ £ S'S s
GENERAL INSTRUCTIONS TO CARRIERS
1. Carriers must furnish tram
>vernment will not be responsih
for on the face of the request must be paid for by the traveler when obtained and not billed against the Government.
... ...rsportation of the class or character and between the points specified in the request. The United States
Government will not be responsible for excess costs occasioned by violation of these Instructions. Transportation exceeding that called
2. Where exceptional conditions require the issuance of transportation differing from that specified in the request, the tj
ite in the following space the actual transportation furnished, tne reason for the difference, and sign the statement:
3. Transportation f
said number.
4. Money must not b
5. Ticket agent's insert id
6. Requests showing erasures or a
BILLING
7. Bills should be prepared by carrier's general officers on Government forms obtainable from
the Public Printer, Washington, D. C., and rendered direct to the issuing bureau or office as shown
on the face of the request.
8. Requests should not be passed through banks for collection.
9. Original requests must accompany bills and be listed thereon by numbers.
10. If original requests are lost, carrier should furnish affidavit explaining loss and showing the
exact service rendered, including date of issue and number of ticket.
Appendix B
Standard 1031
Face and Reverse
"ftie ITnitkh States of America. WPA-306, 556
(fto/t. WORKS PROORBSS ADMINISTKATION. WASHINGTON. P. C. / / j JlrrtAx ' / / '
fteyues/s /fie fa/mptmyfo/umisfi / ^ ^ / / / /
Dompanyrvfurms/t i_ r / / / #
It/SMIf/M
A KyHmtxrr p/7'W»r/rr;
jVOTK-Jbliate.shietfy instn/rttetw a? ;w>.tf4<wnf
Standard Form No. 1031
GOVERNMENT REQUEST FOR TRANSPORTATION
(Memorandum)
Deaorlption Actual alee 7-3/8 by 3-1/8 Inches] 1 page,
" printed face and reverse.
Routing One copy to be prepared together with Standard
Form No. 1030, to Division of Finance and Accounts,
Washington, D. C.
Instructions for Preparation See Operating Prooedure No.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
NOTICE OF ISSUE OF TICKET
1. This memorandum to be detached upon Issue of ticket and immediately mailed to
2. Where a
memorandum until
ually performed by
3. Indicate belo'
struction 2 on reverse
(Administrative Officer)
id onf|e RRBJ^|r Transportation, the traveler will retain this
[ilitjlroirected, routing thereon the journey act-
me varies from that requested. (See In-
Appendix B
Standard 1033
U. S. GOVERNMENT TRANSPORTATION
IDENTIFICATION CARD -
THIS IS TO CERTIFY THAT
(Name of traveler)
(Department or Establishment and Bureau or Service)
£
2 ENGAGED ON
«j (Stato briefly official duties)
.» AND IS AUTHORIZED TO NEGOTIATE GOVERNMENT TRANSPORTATION REQUESTS ISSUED TO HIM I
2 CONNECTION WITH OFFICIAL TRAVEL
(Signature and title of issuing officer)
(Signature and title of head of Department or Establishment, or Bureau or Sorvioe)
Standard Form No. 1033. Form approved by Comptroller General U. 8., May 0, 1020.
G P O 10—1720
Standard Form No. 1033
U. S. GOVERNMENT TRANSPORTATION IDENTIFICATION CARD
Description Actual size 4^ by 2-g inches; card, printed face
only.
Routing Original only, to traveller authorized to issue
Transportation Requests.
Instructions for Preparation See Operating Procedure No. F-20.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix B
Standard 1034
Face and Reveree
Contract No. Pete Reg. No. Pete Invoice Rec'd
Pursuant to authority vested in me, I certify that the above article* were received in good condition, after due inspection, acceptance, and delivery prior to payment as required
by law. or the services were performed as stated; that they were procured under the contract numbered above or the unnumbered contract attached hereto, or that they were
procured without written contract, in open market, and with or without advertising, under the circumstances stated in No of "Method of cr Absence of Advertising"
shown on reverse hereof, and were necessary for the public service; and that the prices charged arc just and reasonable and in accordance with the agreement
I Approved for $ (Sign original only)
Tide
ACCOUNTING CLASSIFICATION (for completion by Administratis Office)
Appropriation, limitation, or
project symbol
Appropriation title
Limlt'n or Proj't
Amount
Appropriation
Amount
Allotment symbol
Amount
Encumbrance
liquidated
COST ACCOUNT
OBJECT OF EXPENDITURE
Symbol
Amount
Symbol
Amount
Paid by
Standard Form No. 1034
(Revised 6-8-37) •
PUBLIC VOUCHER FOR PURCHASES AND SERVICES
OTHER THAN PERSONAL
Description Actual size 8^ by 11 inches; 1 page, printed
face and reverse.
Prepared by State Proourement Office.
METHOD OF OR ABSENCE OF ADVERTISING
(Sao. 3700 of the Kovlwxi BUtutaa)
1. After Advertising in nowspapors.
2. (a) After advertising by circular letters sent to dealer*.
(6) And by notices posted in public places.
(If notices were not posted in addition to advertising by circular luttera sent to dealers, explanation of such omission must
be made. The notation on the certificate on the face of the voucher must be "2(a)(6)" or "2(a)", depending on whether or
not notices were posted.)
3. Without advertising, under an exigency of the scrvico \Vhich existed prior to the order and would not admit of the delay Incident
to advertising.
4. Without advertising in accordance with
5. Without advertising, it being impracticable to 6ecure competition because of
(.Here slat* in detail Lbe nature of the exigency or circumat&uccs under which the securing of competition was Impracticable under 3 and 4)
Note.—The above form "Method of or Absence of Advertising" is to be used when purchases are made or services secured under
proper authority without written agreement in any form. In case of a written agreement (formal contract, proposal, and acceptance, or
less formal agreement) Standard Form No. 1036—Revised should be used for abstracting the method of or absence of advertising and award
of contract. (See General Regulations No. 51, Supplement No. 6, General Accounting Office, Aug. 20, 1930.) u>— nu
Appendix B
Standard 1034a
Face and Reverse
l'orm approved by
Comptroller General, U. B.
June 8, 1037
(Oon. Reg. No. 81, Supp. No. 7)
PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
D. 0. Vim. No. ..
Bu. Veu.
GENERAL ACCOUNTING
OFFICE PREAUDIT
Certified for payment in the
eum of $ -
U.S.
(Department, bureau, or establishment)
Voucher prepared at
THE UNITED STATES, Dr.,
To.. _
Address .
(Olve place and date)
Payee's Account No.
(For use of Paying Office)
Date of Delivery
Articles or Services
(Enter description, Item number of contract or general supply schedule,
and other information deemed neoeasary)
Terms % Discount Cash .............. days
Brought forward from continuation sheet(s)
UNIT PRICE
Shipped from...
Weight.,
Government B/L No..
I certify that the above bill is correct mid just; that payment therefor has not been received; and that except
as otherwise noted all of the articles, materials, and supplies furnished under purchase order No
if unmanufactured articles, materials, and supplies, have been mined or produced in the United States, and if
manufactured articles, materials, and supplies, they have been manufactured in the United States substantially all
from articles, materials, or supplies mined, produced, or manufactured, as the case may be, in the United States.
(Mem oran d uin—Do not sign)
•Payee ..
(Payee must NOT use this apace)
Account verified; correct for
(Signature or initials)
Contract No. _
Req. No. ...... Date _
Pursuant to authority vested in me, 1 certify that the above articles were received in good condition, after due inspection, acceptance, and delivery prior to payment as required
by law, or the services were performed as stated; that they were procured under the contract numbered above or the unnumbered contract attached hereto, or that they were
procured without written contract, in open market, and with or without advertising, under the circumstances stAted in No. of "Method of or Absence of Advertising"
shown on reverse hereof, and were necessary for the public service; and that the prices charged are just and reasonable and in accordance with the aj
fApproved for $...
mdum—Do not sign)
ACCOUNTING CLASSIFICATION (for completion by Administrative Office)
** project symbol
Appropriation title
Limlt'n or Proj't
Amount
Appropriation
Allotment symbol
Amount
Encumbrance
liquidated
COST ACCOUNT
OBJECT OF EXPENDITURE
Symbol
Amount
Symbol
Amount
Paid by
Check No..
Cash. $.....
19....
19....,
., for t f <"* Treasurer of the United States in favor of payee
(named above.
Standard Form No. 1034a
(Revised 6-8-37)
PUBLIC VOUCHER FOR PURCHASES AND SERVICES
OTHER THAN PERSONAL
Description Actual size 8i by 11 inches; 1 page, printed
face and reverse.
Prepared by State Procurement Office; 1 copy to State
Works Progress Administration.
METHOD OF OR ABSENCE OF ADVERTISING
(9m. 3700 of Uio KevUod Statutoa)
1. After advertising In newspapers.
2. (o) After advertising by circular letters sent to doalers.
(6) And by notices posted in public places.
(If notices were not posted in addition to advertising by circular letters sent to dealers, explanation of such omission must
be made. The notation on the certificate on the faco of the vouchor must bo "2(a)(6)" or "2(a)", depending on whether or
not notices were posted.)
3. Without advertising, under an exigency of the servico which existed prior to the order and would not admit of the delay incident
to advertising.
4. Without advertising in accordance with
6, Without advertising, it being impracticable to secure competition becauso of
(H«r« state In detail the nature of the exigency or circumstances under which tbo securing of competition was Impracticable under 3 and 4)
Note.—The above form "Method of or Absence of Advertising" is to be used when purchases are made or services secured under
proper authority without written agreement in any form. In case of a written agreement (formal contract, proposal, and acceptance, or
less formal agreement) Standard Form No. 103(>—Revised should be used for abstracting the method of or absence of advertising and award
of contract. (See General Regulations No. 51, Supplement No. 6, General Accounting Office, Aug. 20, 1930.) io—i7oi
Appendix B
Standard 1044
m No. 1044— RotIkxI
n approrad by Comptroller Uonarnl U. 8.
June 34, IBS®
SCHEDULE OF COLLECTIONS
Received by..
Period
(Department or EitabUihmeDl)
(Name)
(Month or quarter ended)
Nam* or Bemrteh
ScMul, No..
Shut No..
(Bureau or OfDoe)
D. O. Symbol No.
Detail DEscmrriox or Pcbpoee |
for Wntcn Collections Were ,
Beceiveu
Received subject to collection. Forwarded
By
(Die bar-dug clerk or aooountabla offlov)
By
Certificate of Deposit No dated .
Title..
Standard Form No-. 1044
(Revised 6-25-36)
SCHEDULE OF COLLECTIONS
Description Actual alze 8^- by 10 inches; 1 page, printed faoe
only.
Routing Original and five copies as follows: original and first,
second and third copies to Treasury State Disbursing Clerk;
fourth oopy to Treasury State Aooounts Office; fifth oopy re¬
tained by initiating office.
Instructions for Preparation See Handbook of Procedures, chapter
XXI, seotion 32.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
57212 Q—38 15
Appendix B
Standard 1046
SCHEDULE OF TRANSFERS—SPECIAL DEPOSITS
JumM, IW
ScJmduU No.
Sfatf No.
(DaporUnant or Eatabllihmant)
(Bureau or Offloa)
Made by .
Period —
(Month or quarter ended)
D. O. Symbol No. .
nan* or Bkxittm
Amount to be
Tbaiwmrid to
Reoula* Account
The Accountable Officer is authorized to transfer from Special Deposits to his Regular Account and deposit the
total amount shown in the column headed "Amount to be Transferred to Regular Account."
(Sixnature of epprovlug officer)
Title
Certificate of Deposit No Dated
u.«. asviaa.tav mania orrici 10—iraa
Standard Form No. 1046
(Revised 6-25-36)
SCHEDULE OF TRANSFERS-SPECIAL DEPOSITS
Doaorlptlon Actual size 8 by lojjf inchesj 1 page, printed faoe
only.
Routing Original and six copies as follows: original and first,
second, third, fourth, and fifth oopies to Treasury State
Disbursing Clerkj sixth copy retained by initiating offioe.
Instructions for Preparation See Handbook of Procedures, ohanter
1Yi, section 55.
Printed form supplied on request by Worlra Progress Adminis¬
tration, Washington, D. C.
Appendix B
Standard 1058
Face and Reverse
Standard Form No. 1088
roan ArraovKD by
OOUTBOLLKB OlNUAL V. B.
August 34, 1MB
United States of America
Xo..
(Department or Establishment end Bureau or Service)
CAppropristlon chargeable)
GOVERNMENT BILL
OF LADING
ORIGINAL
(Name and title of IboIdi officer)
BcnM from .
(Consignor)
. the public property hereinafter described,
by the
(Name of traneparUUon company)
in apparent good order and condition (contents and value unknown), to be forwarded subject to conditions stated on the reverse hereof,
(Shipping point)
by the said company and connecting lines, there to be delivered in like good order and condition to..
(Route Journey only when tome substantial In tercet of the government la subserved thereby)
NUMBER AND
KIND OV
PACKAGES
DESCRIPTION OF ARTICLES
(Observe itrletly carrier'! freight clawlfloatlon. Avoid trade oi
t^.hniA«i names)
(Signature of Consignor)
TARIFF AUTHORITY
fTo bo filled In by general office rendering account)
(Name of transportation company)
,19 Per
(Date) (Aunt)
AUTHORITY FOR SHIPMENT
CERTIFICATE OF ISSUING OFFICER
(To be filled out when this bill of lading U Issued for use by contractor in making shipment)
.., or Purchase Order No. .
.., dated .
(F. O. B. point named in oontrsct) ~ (Issuing officer}"
(CAWWIOt'g NIQKTS TO EHIPPINQ CHANCES NOT AFFECTED BY FACTE SET OUT IN THIS cntTIFlCATE)
CONSIGNEE'S CERTIFICATE OF DELIVERY
I have this day received from
(Name of transportation company)
. the public property described in this bill of lading,
in apparent good order and condition, exoept as noted on the reverse hereof. Delivery service at destination W£^^ot by the Government.
Weight pound*."'"0
it far lUDBMnU via o<
m whore required.
(Consignee)
19.
(Date)
Standard Form No. 1058
GOVERNMENT BILL OF LADING
(Original)
Description Actual site 8 by lo£ inchesj 1 page, printed face
and reverse.
Prepared and issued by State Procurement Officer.
ADMINISTRATIVE DIRECTIONS
1. Government property will bo transported on tho prescribed form
of Goverumont bill of lading (original, memorandum, and shipping
order), which will bo Identified bv sorlnl numbers.
:2. Through bills of lading will bo Issued In all InstAnoes botwoon
Initial and ultliuato points, except when rates more advantageous to
the Goverumont may bo otherwise secured.
3. When shipments ore mode under contract or special rntos, notation
o( such tact should appear on the (nee of bills of lading.
4. Officers charged with the duty of providing or securing Govern¬
ment transportation should familiar Uo themselves with land-grant
railroads In order that shipments mny be made at tho lowest rates
available to tho Government by tho use of such Unas, or lines equalising
rates therewith.
5. Publlo property may bo delivered by any Government officer or
agent to tho Quartermaster Corps, U. 8. Army, which will ship tho
same under Its regulations. (23 Stat. 111.)
6. Bills of lading must doscrlbe shtpmonts of articles by their com¬
mercial names, giving separately such weights, dimensions, and manner
of packing as may bo necessary to ascertain classifications and rates and
to enable recovery In case of loss or damage. ,
7. If tho number of articles to bo shipped be too great for tbo blank
form (original, memorandum, and shipping ordor), extra shoots of tho
prescribed form should be used, and so attached and designated as to
form but ono bill of lading, under one number.
A A vouchor when submitted for settlement shall cover charges to
one offloo or scrvloo ouly. Tho name of the office Is Inserted at tho top
of the bill of lading. Correspondence regarding transportation accounts
shall bo addressed to the particular office or service and reference made
to the serial numbers of tho Government bills of lading included In tho
company's bill.
REPORT OF LOSS, DAMAGE, OR SHRINKAGE
Notice is hereby given the carrier to whom this bill
of lading is surrendered that the shipment was received
in condition shown below and that claim is made for
the value of such loss, damage, or shrinkage, as
indicated.
Explanation regarding loss, damage, or shrinkage to
be made by consignee, who will state all the facts avail¬
able concerning the nature or extent of the loss,
damage, or shrinkage, and how it occurred.
The within shipment was received with the following
loss, damage, or shrinkage:
Description:
Weight of such articles pounds.
Invoice value or cost of repairs, $
I certify that the facts noted above arc correct.
Consignee.
By
GENERAL CONDITIONS AND INSTRUCTIONS
CONDITIONS
It Is mutually agreed and understood between the United States and carriers who are parties to this bill of lading
that—
1. Prepayment of charges shall In no cose be demanded bv carrier, nor shall collection be made from consignee.
On presentation to the office indicated on the face hereof of this bill of lading, properly accomplished, attached to
freight vouchor prepared on tho authorized Government form, payment will be made to the last carrier, Unless otherwise
specifically stipulated.
2. Unless otherwise specifically provided or otherwise stated hereon, this bill of lading is subject to the same rules
and conditions as govern commercial shipments made on the usual forms provided therefor by the carrier.
3. Shipment made upon this bill of lading shall take no higher rate than would be charged had the shipment been
made upon the uniform straight bill of lading or uniform express receipt.
4. No charge shall be made by any carrier for the execution and presentation of bills of lading in manner and
form as provided by the instructions hereon.
6. This shipment is made at the restricted or limited valuation specified in the tariff or classification at or under
which the lowest rate is available, unless otherwise indicated on the face hereof.
6. Receipt of the shipment is made subject to the "Report of Loss, Damage, or Shrinkage" noted hereon.
7. In case of loss, damage, or shrinkage in transit, the rules and conditions governing commercial shipments shall
not apply as to period within which notice thereof shall be given the carriers or to period; within which claim therefor
shall bo made or suit instituted.
INSTRUCTIONS
1. Erasures, interlineations, or alterations in bills of lading must be authenticated and explained by the person
making them.
2. Shipping order, original bill of lading, and memorandum bill of lading should be used in making a shipment.
Only one original bill of lading will be issued for a single shipment. The shipping order should be furnished the initial
carrier. The original bill of lading and memorandum copies should be signed by the agent of the receiving carrier,
returned to the consignor, and tho original promptly mailed to the consignee. The consignee on receipt of the ship¬
ment will sigh the consignee's certificate on the original bill of lading and surrender the bill of lading to the last carrier.
The bill of lading then becomes the evidence upon which settlement for the service will be made. Memorandum
copies of bills of lading may be used as administrative officers direct.
3. In the absence of the consignee, or on his failure to receipt, the person receipting will certify that he is duly
authorized to do so, reciting such authority.
4. In no case will a second bill of lading be issued for a shipment, nor will a bill of lading be issued after the trans¬
portation has been performed. In case the bill of lading has been lost or destroyed, the carrier shall be furnished by
the consignee with a "Certificate in Lieu of Lost Bill of Lading," on the standard form prescribed therefor which,
when finally consummated by acknowledgment of the "Certificate and Waiver by Transportation Company," shall
accompany the bill for services submitted by the carrier to the officer charged with the settlement of the acsount.
Should the original bill of lading be located after settlement has been made on the certificate, it will be forwarded to
the administrative office of the department concerned for transmittal to the General Accounting Office.
5. To insure prompt delivery of property, in the absence of the bill of lading, the consignee should give to the
carrier a "Temporary Receipt," executed on the prescribed form, for the property actually delivered. On toe recovery
of the bill of lading, or when the certificate provided for above shall have been given, a statement will be indorsed on
said bill of lading or certificate of the fact of the delivery as pier said temporary receipt, and toe said temporary receipt
will be indorsed with reference to the bill of lading or certificate sufficient to identify the same, and both papers attached
and forwarded with the claim for payment thereon.
6. In case of loss or damage to property while in the possession of the carrier, such loss or damage shall, when
practicable, be noted on the bill of lading or certificate in lieu thereof, as the case may be, before its accomplishment.
All practicable steps shall be taken at that time to determine the loss or damage and the liability therefor, and to collect
and transmit to the proper officer, without delay, all evidence as to the same. Should the loss Or damage not be dis¬
covered until after the bill of lading or certificate has been accomplished, the proper officer shall be notified as soon
as the loss or damage is discovered, and the agent of the carrier advised immediately of such loss or damage, extending
privilege of examination of shipment.
7. Bills must be submitted by the general officers of carriers, and on forms furnished by toe Government, to be
obtained from the Public Printer, Washington, D. C. 10-137* o i conuaur pumas om«
Appendix B
Standard 1058a
Standard Form No. 1008a ,, _ .
^ Foau approved dt _ UNITED STATES OF AMERICA
COUPTEOUJEJt GENERAL U. 8.
August H 1028 Jfo. _
(Department or Ettabllshment end Bureau or Bervloe)
(Appropriation chargeable)
GOVERNMENT BILL "(Name" and "title of" issuing offleerj" "(Date isaied j '
OF LADING
MEMORANDUM COPY SpCBitljil from
(Consignor)
by the the public property hereinafter described,
(Nemo o< transportation company)
in apparent good order and condition (contents and value unknown), to be forwarded subject to conditions stated on the reverse hereof,
from to _
(Shipping point) (Destination)
by the said company and connecting lines, there to be delivered in like good order and condition to
(llouto joumoy only when some substantial Interest of the Government Is subsorvod thereby;
NUMBERS ON II°KINDROFND I
PACKAGES p¥rNKD*GRR
DESCRIPTION OF ARTICLES
(Observe strictly canier's freight classification. Avoid trade or WEIGHTS*
technical names)
Pick-up service at origin
(Size car ordered ft. Size car furnished ft. Date furnished..
- Initials Car No.
}
AUTHORITY FOR SHIPMENT
(Name of transportation company)
..., 19 Per
CERTIFICATE OF ISSUING OFFICER
(To bo filled out when this bill of lading Is issued for use by contractor in making shipment)
Contract No , or Purchase Order No. ...
, dated
, 19
(P. O. B. point named in conlruct) (Issuing officer) "
(CARRIER S RIGHTS TO SHIPP1NC CHANGES NOT AFFECTED BY FACTS SET OUT IN THIS CERTIFICATE)
MEMORANDUM COPY
Delivery service at destination wt^ot by the Government
* Show also cublo measurement for shipments via ocean carrier in cases where required.
o(> Furnish this Information in case of carload shipments only.
Standard Form No. 1058a
GOVERNMENT BILL OF LADING
(Memorandum)
Description Actual size 8 by 10j| inches; 1 page, printed
face only.
Prepared and issued by State Proourerent Officer.
Appendix B
Standard 1059
Face and Reverse
ran No. 1009
FOBU arraoTiD ST
COMRBOIXU OlNSRAL V. B.
August 34, 1938
United States of America
No...
(To be delivered to the Agent
of the receiving Transportation
Company for h» nee)
GOVERNMENT BILL
OF LADING
SHIPPING ORDER
(Department or Establishment unil Bureau or Bervlae)
(Name and title of Issuing o:
Pltaae for.
19-
(Consignor)
by the - the publio property hereinafter described,
(Name of transportation company)
in Apparent good order and oondition (contents and value unknown), to be forwarded subject to conditions stated on the reverse hereof,
(Shipping point) (Destination)
by the said company and connecting lines, there to be delivered in like good order and condition to...
(Route journey only whan some substantial Interest of tha Government is subserved thereby)
NUMBER AND
KIND Of
PACKAGES
DESCRIPTION OF ARTICLES
(Observe strictly carrier's freight classification. Avoid trade or
technical names)
\ Size car ordered. ft. Size car furnished ft. Date furnished. Initials Car No...
Consignor.
t Furnish this information tr
» of carload shlsments ooir.
Standard Form Noe 1059
GOVERNMENT BILL OF LADING
(Shipping Order)
Description Aotual size 8 by 10f inches; 1 page, printed
face and reverse.
Prepared and issued by State Procurement Officer.
ADMINISTRATIVE DIRECTIONS
1. Government property will be transported on tho
prescribed form of Government bill of lading (original,
momorandum, and shipping order), which will be
identified by sorial numbers.
2. Through bills of lading will be issuod in all
instances botween initial and ultimate points, except
when rates more advantageous to tho Government may
ye otherwiso secured.
3. When shipments aro made under contraot or
special rates, notation of such fact should appear on
tho face of bills of lading.
4. OiTicors charged with the duty of providing or
securing Government transportation should familinrizo
themselves with land-grant railroads in order that ship¬
ments may be mado at tho lowest rates available to tho
Government by tho use of such liuee, or liuea equalis¬
ing rates therewith.
5. Public property may bo delivered by any Govern¬
ment officer or agent to the Quartermaster Corps, U. S.
Army, which will ship tho same under its regulations.
(23 Stat. 111.)
6. Bills of lading must describe shipments of articles
by their commercial names, giving separately such
weights, dimensions, and manner of packing as may bo
necessary to ascertain classifications and rates and to
onable recovery in case of loss or damage.
7. If the number of articles to be snipped be too
great for the blank form (original, memorandum, and
shipping order), extra sheets of the prescribed form
should be used, and so attached and designated as to
form but one bill of lading, under one number*
8. A voucher when submitted for settlement shall
cover charges to one office or service only. The name
of the office is inserted at the top of the bill of lading.
Correspondence regarding transportation accounts shall
be addressed to the particular office or service and
reference made to the serial numbers of the Govern¬
ment bills of ladiug iucluded in the company's bill.
GENERAL CONDITIONS AND INSTRUCTIONS
CONDITIONS
It Is mutually agreed and understood between the United States and carriers who are parties to this bill of lading
that—
1. Prepayment of charges shall in no case be demanded by carrier, nor shall collection be made from consignee.
On presentation to the office indicated orr the faco hereof of this bill of lading, properly accomplished, attached to
freight vouchor prepnrod on the authorized Government form, payment will be made to the last carrier, unless otherwise
specifically stipulated.
2. Unless otherwise specifically provided or otherwise stated hereon, this bill of lading is subject to the same rules
oud conditions as govern commercial shipments made on the usual forms provided therefor by the carrier.
' 3. Shipment made upon this bill of lading shall take no higher rate than would be charged had the shipment been
made upon tho uniform straight bill of lading or uniform express receipt.
4. No chargo shall be made by any oarrier for the execution and presentation of bills of lading in manner and
form as provided by the instructions hereon.
5. 'lhis shipment is made at the restricted or limited valuation specified in the tariff or classification at or under
which the lowest rate is available, unless otherwise indicated on the face hereof.
6. Receipt of the shipment is made subject to the "Report of Loss, Damage, or Shrinkage" noted hereon.
7. In case of loss, damage, or shrinkage In transit, the rules and conditions governing commercial shipments shall
not apply as to period within which notice thereof shall be given the carriers or to period within which claim therefor
shall be mode or suit instituted.
INSTRUCTIONS
1. Erasures, interlineations, or alterations in bills of lading must be authenticated and explained by the person
making them.
2. Shipping order, original bill of lading, and memorandum bill of lading should be used in making a shipment.
Only one original bill of lamng will be issued for a single shipment. The shipping order should be furnished the initial
carrier. The original bill of lading and memorandum copies should be signed by the agent of the receiving carrier,
returned to the consignor, and the original promptly mailed to the consignee. The consignee on receipt of the ship¬
ment will sign the consignee's certificate on the original bill of lading and surrender the bill of lading to the last carrier.
The bill of lading then becomes the evidence upon which settlement for the service will be made. Memorandum
copies of bills of lading may be used as administrative officers direct.
3. In the absence of the consignee, or on his failure to receipt, the person receipting will certify that he is duly
authorized to do so, reciting such authority.
4. In no case will a second bill of lading be issued tor a shipment, nor will a bill of. lading be issued after the trans¬
portation has been performed. In case the bill of lading has been lost or destroyed, the carrier shall be furnished by
the consignee with a "Certificate in Lieu of Lost Bill of Lading," on the standard form prescribed therefor which,
when finally consummated by acknowledgment of the "Certificate and Waiver by Transportation Company," "hall
accompany the bill for services submitted by the carrier to the officer charged with the settlement of the account.
Should the original bill of lading be located after settlement has been made on the certificate, it will be forwarded to
the administrative office of the department concerned for transmittal to the General Accounting Office.
6. To insure prompt delivery of property, in the absence of the bill of lading, the consignee Bhould give to the
carrier a "Temporary Receipt." executed on the prescribed fprm, for the property actually delivered. On the recovery
of the bill of lading, or when the certificate provided for above shall have been given, a statement will be indorsed on
said bill of lading or certificate of the fact of the delivery as per said temporary receipt, and the said temporary receipt
will be indorsed with reference to the bill of lading or certificate sufficient to identify the same, and both papers attached
and forwarded with the claim for payment thereon.
6. In case of loss or damage to property while in the possession of the carrier, such loss or damage hHrU, when
practicable, be noted on the bill of lading or certificate in lieu thereof, as the case may be, before its accomplishment.
All practicable steps shall be taken at that time to determine the loss or damage and the liability therefor, ana to collect
and transmit to the proper officer, without delay, all evidence as to the same. Should the loss or damage not be dis¬
covered until after the bill of lading or certificate has been accomplished, the proper officer shall be notified as soon
as the loss or damage is discovered, and the agent of the carrier advised immediately of such loss or damage, extending
privilege pf examination of shipment.
7. Bills must be submitted by the general officers of carriers, and on forms furnished by the Government, to be
obtained from the Public Printer, Washington, D. C. io—ists
mihtihs off1ci
Appendix B
Standard 1064
Standard Form No. 10M
oJgSggtV.e SCHEDULE OF DISBURSEMENTS
(Dqartment or eetabllahment) (Bureau or offio.) (Date paid)
^ (Name) (Title or rank) (Station)
Period - Symbol No.
(Month or quarter ended)
Bureau Schedule No — Date —
rasBOTtsnja
officer's
vouchee ho.
FOI
gjlo.
ohu
(/>
bubeau oe
office
vouchee ho.
payee
symbol op appsopuatioh
oe fuhd
amoubt
1
!
i
1
j
To the General Aocountojo Omcs:
The foregoing accounts and/or-claims have reoeived administrative examination and have been approved for payment In the
amounts stated.
(Signature ot uatlfjlm offloa) (TBI.)
Standard Form No. 1064
SCHEDULE OF DISBURSEMENTS
Description Actual sire 8 by 10j| inches,; 1 page, printed
face only.
Routing Originalraiid Your .copies as follows: (.original
three cppiets to .Treasury State Accounts Office; fourth
copy retainedvhyLDivision,of Finance.
Instructions for Preparation See"Handbook of Procedures,
chapter XXI, section 22 and Operating Procedure No. F-9.
Printed form supplied on request by Works Progress Ad¬
ministration, Washing ten, D. C.
Appendix B
Standard 1070
SthaduU No
Form approved by Oomptrolkr OaamJ U. «.
SCHEDULE OP
RETIREMENT AND DISABILITY FUND CREDITS
ShmtN*,....
By
(Dopartmant or KatebUahman
)
(Bonaa or Offlo.)
(Noma)
(Tltte)
(Station)
(Month or quarter orated)
° Numbsb
bubbau ob ottos
vooceu numbsb
amount op RrmiKBHT
deduction#
D. 0. Vouchee
Numbbb
Bubbav ob Optics
Vouches Nora sb
Amount op BmBnoirr
Deductions
Total, fo»wi«n
Total
Depoait(a) with Tre
aaurer U. 8.:
Check No.
Cheok No
Check No. .
Check No. .
no office io—soie
Standard Form No. 1070
(Revised 6-25-36)
SCHEDULE OF RETIREMENT AND DISABILITY FTJND CREDITS
Description Actual size 8 by 10& inchesj 1 page, printed
face only.
Routing Original and seven copies as follows: original and
first, second, third, fourth, fifth and sixth oopies to
Treasury State Aocounts Officej seventh oopy retained by
Division of Finance.
Instructions for Preparation See Handbook of Procedures,
ohapter XXI, section 34.
Printed form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
Appendix B
Standard 1080
Form approved by
Comptroller Central, U. 8.
Augufl 17. 1037
Oeneral Regulations No. 78—RovlicU
u. s
To U. S. .
VOUCHER FOR ADJUSTMENTS
BETWEEN APPROPRIATIONS AND/OR FUNDS
(DISBURSEMENT)
Dr.
D. O. Vou. No. A..
Bill No
Paying Office No. ..
(Department, establishment, bureau, or office billed)
(Dopartment, establishment, bureau, or oflloe billing)
ARTICLES OR SERVICES
UNIT PRICE
Dollar* Cants
CERTIFICATE OF BILLING OFFICE
I certify that the above bill is correct and just; that the items are
commuted in accordance with the coat of labor and/or material; and
that the amounts listed are properly creditable to the appropriation (s)
and/or fund(s) as indicated; or that the advance payment requested
is authorised by law and is properly creditable to tne appropriation(s)
and/or fund(s) as indicated.
(Signature of officer In control of appropriation to be credited)
(Forussof billed o
Differences
Account verified; correct for S
(Signature or initials)..
CERTIFICATE OF OFFICE BILLED
I certify that the above articles were received and accepted or the services performed as stated and should be debited to the appro¬
priation (s) and/or fund(s) as indicated; or that the advance payment requested is approved and should be debited to the appropriation(s)
and/or fund(s) indicated.
(Signature of officer In oontrol of appropriation to be debited)
APPROPRIATION,
LIMITATION, OR
PROJECT SYMBOL
APPROPRIATION TITLE
LIMITATION
OR PROJECT
APPROPRIATION
Amount
Amount
ALLOTMENT SYMBOL
AMOUNT
ENCUMBRANCE
LIQUI DATED
COST ACCOUNT
OBJECT OF EX
PENDITURE
Symbol
Amount
Symbol
Amount
Standard Form No. 1080
(Revised 8-17-37)
voucher for adjustments between appropriations
and/or funds
(Disbursement)
Description Actual size 8 by 10£ inches; 1 page, printed face
only.
Routing Original only, to Treasury State Accounts Office.
Instructions for Preparation See Operating Procedure No. F-18.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
Standard 1080a
Standard Form No. 1060 a— RctIimI
cJSSgESft... VOUCHER FOR ADJUSTMENTS
_ .A h. BETWEEN APPROPRIATIONS AND/OR FUNDS
(DISBURSEMENT)
D. O. Vou. No. A...
Bill No. -
Paying Office No.
U. S. .
To U. S. .
(Department, wUbllihmeot, bureau, or offloa bUlad)
(Department, establishment, bureau, or office billing)
Dr.
(For UH of paying office)
ARTICLES OR SERVICES
UNIT PRICE
MEMORANDUM
(For um of billed office only)
Differences
Account verified; correct for_ _$
(Signature or initials) —
ACCOUNTING CLASSIFICATION (for completion by office billed)
APPROPRIATION,
LIMITATION, OR
PROJECT SYMBOL
APPROPRIATION TITLE
APPROPRIATION
ALLOTMENT SYMBOL
COST ACCOUNT
OBJECT OF EXPENDITURE
Standard Form No. 1080a
(Revised 8-17-37)
voucher for adjustments between appropriations
and/or funds
(Memorandum Disbursement)
Desoription Aotual site 8 by 10^ inohes; 1 page, printed face
only.
Routing Two copies, to be prepared together with Standard Form
No. 1080 Revised: first oopy to Treasury State Accounts
Office; second copy retained by office billed.
Instructions for Preparation See Operating Procedure No. F-13.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
57212 0—38 16
Appendix B
Standard 1080b
Ntudm I arm No. 1080 b-RnMI
ComptrollerTlBooiahT'. 8.
Auguit 17. 1M7
Oemend Regulation! No. 78—Revlard
u. s
To U. S. .
VOUCHER FOR ADJUSTMENTS
BETWEEN APPROPRIATIONS AND/OR FUNDS
(COLLECTIONS)
Dr.
D. O. Vou. No. A.
Bill No
Paying Office No
PAID BY
(Doportmant, oMabliibmeot, bureau, or office billing)
• of paying office)
DATE OF
DELIVERY
ARTICLES OR SERVICES
UNIT PRICE
Dollar* Canta
CERTIFICATE OF BILLING OFFICE
I certify that the above bill is correct and just; that the items are
commuted in accordance with the cost of labor and/or material; and
that the amounts listed are properly creditable to the appropriation (a)
and/or fund(s) as indicated; or that the advance payment requested
is authorized by law and is properly creditable to the appropriation (a)
and/or fund(s) as indicated.
(Bignatura of ore car in oontrol of appropriation to ba credited)
(For ui. of billed offic* only)
Differences
Account verified; correct for...
(Signature or Initials)..
CERTIFICATE OF OFFICE BILLED
I certify that the above articles were received and accepted or the services performed as stated and should be debited to the appro¬
priation^) and/or fundfs) as indicated; or that the advance payment requested is approved and should be debited to the appropriation(s)
and/or fund(s) indicated.
(Signature of officer In control of appropriation to be debited)
APPROPRIATION.
LIMITATION, OR
PROJECT SYMBOL
APPROPRIATION TITLE
LIMITATION
OR PROJECT
APPROPRIATION
Amount
Amount
COLLECTIONS
Standard Form No# 1080b
(Revised 8-17-37)
VOUCHER FOR ADJUSTMENTS BETWEEN APPROPRIATIONS
AND/OR FUNDS
(Collections)
Description Actual size 8 by 10^ inchesj 1 page, printed faoe
only.
Routing One copy, to be prepared together with Standard Form
NoT 1080 Revised, to Treasury State Aocounts Office.
instruotions for Preparation see Operating Procedure No. F-19.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix 5
Standard 1080c
Standard Form No. 1000 o—RavtaMl
A Usui. II. I ■« I
Onnl Refutation! No 7S—Revtaed
u. s
To U. S. .
VOUCHER FOR ADJUSTMENTS
BETWEEN APPROPRIATIONS AND/OR FUNDS
(COLLECTIONS)
D. O. Vou. No. A..
Bill No.
Paying Office No. .
(Department, ettebltal
, Dr.
ART1CU5 OR SIR VICE3
1S4?"
MEMORANDUM
Total,
(For UM of billed oAee only)
Account verified; correct for $
(Signature or lnitiala).
ACCOUNTING CLASSIFICATION (for completion by billing office)
APPROPRIATION.
LIMITATION. OR
PROJECT SYMBOL
APPROPRIATION TITLE
COLLECTIONS
Standard Form No. 1080o
(Revised 8-17-37)
voucher for adjustments between appropriations
and/or funds
(Memorandum Collections)
Description Actual size 8 by 10^ inches; 1 page, printed
Taoe only.
Routing One copy, to be prepared together with Standard Form
No. 1080 Revised, retained by billing offioe.
Instructions for Preparation See Operating Procedure No. F-13,
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix B
Standard 1081
No. 1081—Rarlaod
nptrolkr Oanusl u. B
luaa SB, lQkB
n approval by Oomptrollar C
SCHEDULE OF ADJUSTMENTS
Sohedule No. .
Sheet No. .....
(Dcpartmant or KatablUhmaat)
whose funds are to be debited.
whose funds are to be credited.
Made by..
Period ...
(Month or quarter and ad)
(Place)
D. O. Symbol No...
Paid by cheek No..
I on Treasurer of the United States
\ in favor of "Treasurer U. 8. for deposit."
Certificate of Deposit No...
Standard Form No. 1081
(Revised 6-25-36)
SCHEDULE OF ADJUSTMENTS
Description Aotual size 8 by lOg inches; 1 page, printed
face only.
Routing Original and seven copies, to accompany Standard
Form No. 1080 Revised; original and first, second, third,
fourth, fifth and sixth copies to Treasury State Accounts
Office; seventh copy retained by office billed.
Instructions for Preparation See Operating Procedure No. F-13.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix B
Standard 1094
Face and Reverse
U. S. Oovtrnmtnt Tax Eumptlon Cartlflcata
Standard Form No. 1094
Form approved by
Comptroller General U. S., June 19, 1936
I certify that I have purchased for the exclusive use of the United States Govern¬
ment from
(Name of vendor)
(Address of vendor)
WPA-5
INDICATE AMOUNT OF TAX
KIND
INCLUDKD
EXCLUDED
Federal
XXX
$
•State
$
»
•Local
f
t
which his (or have) been delivered, or*
No dated
Date.
>d pMfcint to purchase orders issued under contract
exenpion certificate has not heretofore been issued.
(Signature and title of purchaser)
(Identification Card No.)
VENDOR Certified correct and Just; II To be filled In ONLY by the administrative office when a State or
Firm Name local tax Is Included in the purchase price.
By -
Title
Symbol.
Bu. Vou. No Period.
'State and local taxes to be paid only when abaolutely necessary to obtain commodity required.
Standard Form No. 1094
0. S. GOVERNMENT TAX EXEMPTION CERTIFICATE
Description Actual size 7-3/8 by 3-3/6 inohes; 1 page, printed
faoe and reverse.
Routing Original only, to vendor or submitted with payment
voucher depending upon whether purchase price is exclusive
or inclusive of Federal, State, or looal tax.
Instructions for Preparation See Operating Prooedure No. F-20
and reverse of form.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
INSTRUCTIONS
1. This form will be used where a State or local sales tax attaches at the time of sale to the consumer and/or when the merchandise
purchased is subject to the Federal tax Imposed by the Revenue Act of 1932, as amended, and it oan be definitely established at the time
of purchase that such Federal tax is not Included In the amount paid by the purchaser.
2. Using a separate certificate for each class of tax Involved, the certificate will be Issued to the vendor when the price paid is ex¬
clusive of the Federal. State, or local tax, and will be retained by the purchaser when the price paid Includes a State or local tax.
3. The serial number of each certificate prepared will be shown on the payment voucher.
4. If the space provided for showing the quantity, price, etc., of the articles purchased Is not sufficient, a separate statement may be
attached to the form.
5. Exemption certificate will NOT be i
fa) For merchandise purchased which Is ed in the price paid.
(b) For items of subsistence expense * :nt is traveling on official business under
a per diem allowance.
(c) For items of travel expense when an ol^^al or empRyit^f the F^Rral GPRPflWent is traveling on official business In his per¬
sonally-owned motor vehicle and Is granted a mileage allowance.
(d) By individuals in official travel status, unless payment Is actually made at the time of purchase.
PENALTY FOR FRAUDULENT USE
The fraudulent use of this certificate for the purpose of securing exemption from the payment or adjustment of taxes will subject
the guilty party to a fine of $10,000 or imprisonment for not more than 10 years or both.
Appendix B
Standard 1094o
U. S. GOVERNMENT TAX EXEMPTION
IDENTIFICATION CARD
WPA-4772
(Good until) TH|S 1S T0 CERT,FY THAT
■h mm yc
1 WHOHASSA|EDHIKPM^0^Vm,N H
MM MM
■OF.
B^^R^TEE OF THE
EstablisbnMAnd •®iu orBMice) II
2 ENGAGED ON lM|flvERN VIl BUSimflf AN! 1 AuMrIZEdJ*ECU RE EX-
2 EMPTION FROMVHAL.STll|uiJWAxd|uClllSAyM. GASOLINE
a TA x. E'TC.) 0 N 1d MA N D1S E P^^^K^F0 R E ftftj S1 S E • A N D F 0 R
""THIS PURPOSE WlW PRESENT T<^W!PERS FROHWhOMRPWWSED THE STAND¬
ARD FORM OP U.S. GOVERNMENT TAX EXEMPTION CERTIFICATE (STANDARD FORM
NO. 1094).
STANDARD FORM JtO. 1094 C
FORM APPROVED BY
Signature)
JUNE 19. 1936
(Title)
Standard Form No. 1094c
U. S. GOVERNMENT TAX EXEMPTION IDENTIFICATION CARD
Description Actual size 4^ by 2^ inohes; card, printed face
only.
Routing Original only, to employee to be used in conjunction
with Standard Form No. 1094.
Instructions for Preparation See Operating Procedure No. F-20.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix b
Standard 1096
•pp",i«d by^Coinptroltar ■o-r^... schedule of voucher deductions
Made by..
Period
(Department or Eiubllihrnint)
(Nam*)
(Month or quArtor onded)
(Bureau or Office)
D. 0. Symbol No..
Total,
The accountable officer will deposit the total amount shown in the column headed "Amount of Deduction.'
(Signature of approving officer)
Dcposit(s) with Treasurer, U. S.:
Check No. , dated , for $ ; C/D No..... ....... dated....
Check No.
, dated .
for $ ..; C/D No , dated _
.eovcuNMCNT raixriNS ornci 10—2S23
Standard Form No. 1096
SCHEDULE OF VOUCHER DEDUCTIONS
Description Actual site 8 by lOjj inches; 1 page, printed faoe
only.
Routing Original and six copies as follows: original and first,
seoond, third, fourth and fifth copies to Treasury State
Accounts Office; sixth copy retained by Division of Finance.
Instructions for Preparation See Handbook of Prooedures, chapter
XXI, section 35.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
APPENDIX B
TREASURY FORMS
Appendix B
Standard 1097
Standard Form No. 10*7
Form approved by Comptroller Qantrml, U. B.
AoiurtiT. i«T Reference No...
O coral RagwlaUooi No. 7»-B«vlMd
REQUEST FOR CORRECTIONS IN APPROPRIATION, FUND,
LIMITATION, AND OFFICIAL PROJECT ACCOUNTS
(Daputmant or aaUbUahinant)
Chief, Accounting and Bookkeeping Division,
General Accounting Office,
Washington, D. C.
Adjustment is necessary to correct errors in the accounts of
at , disbursing symbol No.
(Dlnburalng officer)
, as follows:
Reference
(Voil, Schedule,
or C/D Number)
Pebiod or
Account
Appropriation, Limitation, and Project Symbol
To be charged
full explanation of erbob and season for adjustment
(Signature of approving officer)
fob general accounting office use
Action taken:
Approved—as submitted—as corrected
Disapproved
Chief, Accounting and Bookkeeping Section.
Date , By
Standard Form No. 1097
REQUEST FOR CORRECTIONS IN APPROPRIATION, FUND
LIMITATION, AND OFFICIAL PROJECT ACCOUNTS
Description Aotual size 8 by 10^ inches; 1 page, printed faoe
only.
Routing Original and six oopies as follows: original, first,
second, third, fourth and fifth copies to Treasury State
Accounts Office; sixth copy retained by initiating office.
Instructions for Preparation See Operating Procedure No. F-48.
Printed form supplied on request by Works Progress Adminis¬
tration, Washington, D. C.
Appendix E
Treasury A-l
Pace and Reverse
U.«. TREASURY DEPARTMENT
Aero vim and Daroma
(Administrator of approved allocation)
ADVICE OF ALLOCATION
Advice No.
This xa to Cxbtitt Tiiat the President of the United States has allooated from the appropriation made by the "Emergency
Relief Appropriation Act of 1036" the sum of $ which has been set up on the accounts of the Treasury
Department under the following appropriation symbol and title:
Act
Symbol Title.— Limitation —
There is given on the attaohed schedule a detailed list of the official projects covered by this allocation.
Please prepare a Project Authorization (Form A—2) for each official project under this allocation and forward It in quintupll-
cate to the Chief Accountant, Office of Commissioner of Accounts and Deposits, Treasury Department, Washington, D. C. If the
official projeot is of general charaoter covering more than one locality and is subject to administrative authorization, please prepare
a separate form for each amount to be set up on the books of the Treasury Department for expenditure by each State or District
Administrator.
Warrant No..
(For Commissioner of Accounts and Deposits)
Warrant Date
ADMINISTRATOR'S RECORD OF PROJECT AUTHORIZATIONS FROM ABOVE ALLOCATION (Posted from Form A-2 and A-2a)
Date
Offloia)
Projeot No.
Project
Anth. No.
Projeot
Project Authorizations'
Appropriation Allocation 1
Available Balance
> Redactions to be abown In red ink.
Treasury Form A-l
ADVICE OF ALLOCATION
Description Actual size 8 by lOg inches; 1 page, printed
face and reverse.
Prepared by Treasury Department, Washington, D. C. for
advising the Federal Works Progress Administration of
the allocation of funds.
ADMINISTRATOR'S RECORD OF PROJECT AUTHORIZATIONS FROM ABOVE ALLOCATION—Continued
Project Authorisation* >
Appropriation Allocation 1
Available Dalanoo
I
> Redactions to be ihown In red Ink
Appendix E
Treasury A-la
Form A—la
U. 8. TREASURY DEPARTMENT
Accounts and Dire
' ADVICE OF CHANGE IN ALLOCATION
To: Advice No. ..
(Administrator oI Appro**! Allocation)
193
Amount of Change:
Increase, S
Decrease, $.
This is to Certify That Advice of Allocation No. , dated .
covering the allocation of $ made by the President of the United States from the appropriation
under the "Emergency Relief Appropriation Act of 19S6" and chargeable to the following appropriation symbol and title:
Symbol , Title _
has been amended as follows:
Act
, Limitation .
There is given on the attached schedule a detailed list of the official projects affected by this change in allocation.
Please prepare an Advice of Change in Project Authorization (Form A-2a) for such Project Authorisations heretofore
approved and issued by you as may be affected by this change in allocation, and forward such form in quintuplicate to the Chief
Accountant, office of Commissioner of Accounts and Deposits, Treasury Department, Washington, D. C.
Warrant No. ...
Warrant Date .
(For Commissioner of Aceoanta and Deposits)
Treasury Form A-la
ADVICE OF CHANGE IN ALLOCATION
Description Aotual size 8 by 10^ inches; 1 page, printed
face only.
Prepared by Treasury Department, Washington, D. C., for
advising the Federal Vforks Progress Administration of
changes in the allocation of Hinds.
Appendix B
Treasury A-2
Paoe and Reverse
im.ppr.^5joompwi«a«miD .. ADVICE OF PROJECT AUTHORIZATION
Advice No. .
To: The Commissioner of Accounts and Deposits,
U. 8. Treasury Department,
Washington, D. C.
This is to Certify That from the allocation made by the President of the
United States as covered by Advice of Allocation No. ,
Amount of
Project Auth., $~
Official
Project No...
dated
.. , 193 , the above amount, chargeable to the
appropriation symbol and title indicated, is hereby made available for allotment by the
State Administrator shown below:
Location of project
Character or purpose:
(Olty)
(Ooonty)
(State)
FOB USB OF TEKASUHY DEPARTMENT
Location
Symbol
Type of
work symbol—
.. ipriation
symbol
Appropriation
to be charged: Symbol-.
(State Administrator)
All Advices of Allotment (Form A-3) issued under this Project Authori¬
sation must show the above appropriation symbol and title and the Project
Authorization Advice number. Copies of all Buch Advices of Allotment
must be forwarded to:
Accountant In Charge,
U. S. Treasury State Accountb Office,
(Signature of administrative offioor)
(Department or aewwy)
Amount of above project authoriza¬
tion credited on the accounts of this offioe:
STATE ADMINISTRATOR'S RECORD OF ALLOTMENTS ISSUED (Posted from Form A-3 and A-Sa)
To Whom Issued
Project Authorisations1
Unallotted Balance
1 Reductions to bo shown in red ink.
Treasury Form A-2
ADVICE OF PROJECT AUTHORIZATION
Description Aotual site 8 by loj inches; X page, printed
face and reverse.
Prepared by Federal Works Progress Administration
in an original and four copies, as follows: original
to State Works Progress Administrator, first copy to
Treasury State Accounts Office; second copy to Comptrol¬
ler General; third copy to Treasury Department, Wash¬
ington, D. c.; fourth copy to Federal Works Progress
Administration.
Instructions for Preparation See Handbook of Procedures
chapter XX, section 3.
STATE ADMINISTRATOR'S RECORD OT ALLOTMENTS ISSUED—Continued
Allotment
Wort
To Whom booed
Project Authorisations 1
Unallotted Dalanoe
No.
rroJoelNo.
1 BadoctloDS to b* shorn to red Infc o.s. Mnuiin maris* errici *—1M10
Appendix B
Treasury A-2a
Form A-Ba
U. B. TREASURY DEPARTMENT
ACCOUNT* AND DlPOalTA
J'orm approved by Comptroller Oonanl U. 8,
June IS, 1DM
ADVICE OF CHANGE IN PROJECT AUTHORIZATION
To: Tub Commissioner or Accounts and Deposits
U. S. Treasury Department,
Waahington, D. C.
Advice or
Chanob No. .
Sib:
Tnis is to Certify That the Project Authorisation made under Advice
No dated _ , 193 , and chargeable to appropriation
Symbol Title - - ,
is amended as follows:
Amount of change:
Increase, S
Decrease,
Official
Project No.
Project Auth.
AdWce No
' FOB USE OF TREASURY DEPARTMENT
Location
Syznbal ...
Type of
Work Symbol..
Symbol"
Appropriation
Symbol
(Signature of administrative officer)
(State Administrator)
The amount of the increase or decrease In the Project Authorisation as above
indicated shall be entered by the State Administrator on his copy of-the Project
Authorization Advice concerned, and the balance thereof adjusted accordingly.
Accountant in Charge,
U. S. Treasury State Accounts Office,
(Department or agency)
Amount of above change recorded on the
accounts of this office.
Treasury Form A-2a
ADVICE OF CHANGE IN PROJECT AUTHORIZATION
Description Actual site 8 by 10^ inchesj I page, printed
face only.
Routing Prepared by Federal Works Progress Administration
in an original and four copies, as follows: original
to State Works Progress Administrator; first copy to
Treasury State Accounts Office; second copy to Comp¬
troller General; third copy to Treasury Department,
Washington, D, C,; fourth oopy to Federal Works Progress
Adminis tration•
Instructions for Preparation See Handbook of Procedures,
oahpter XX, section 3.
Appendix B
Treasury A-2d
tyBL) K A'HTM'F. N T No
Date —
Series..
ADVICE OF STATE MONTHLY BUDGET
To: State Administrator.
19S..
You are authorized to allot for the month of the following amounts from appropriations
available for the ,
APPROPRIATION TITLE
Finance Director.
RECORD OF ALLOTMENTS TO WORK DISTRICTS
DATE MENT
DIST. APPRQPRIA-
NO. TION SYMBOL
ALLOT-
AMOUNT DATE MENT N0".' TION SYMBOL
DIST. APPROPRIA-
AMOUNT
Treasury Form A-2d
(Revised)
ADVICE OF STATE MONTHLY BUDGET
Description Actual size 8 by 10^ inchesj 1 page, printed
faoe only.
Routing Prepared by Federal Works Progress Administration
in an original and tiro copies, as follows* original
and second copy to State Works Progress Administrator!
first copy retained by the Federal WorkB Progress Ad¬
ministration.
Instructions for Preparation See Operating Procedure No.
F=if;
Appendix B
Treasury A-4
u. a TH^^Sffu-aTM.NT VOUCHER DISTRIBUTION
AOOOVKT. HO UtPOimi 0» " ™
Voucher No 193
Requisition or P. 0. No
APPROPRIATION
TREASURY
OFFICIAL
W P. A.
AUTHORIZATION
LOCATION
TREASURY
VOUCHER No
TYPE OP WORK
SYMBOL
OBJECT OF EXPENDITURE
CODE
AMOUNT
10
21
22
31
32
33
41
42
43
51
52
53
54
55
56
57
60
70
81
82
Rent:
Construction, maintenance, and repair contracts:
Grants:
Contractual services:
Other
Loans:
TOTAL OF ATTACHED VOUCHER.
Fnnimlwinrc to be liquidated
Encumbrance adjustment < "lcrcase i __ _ __
a—1MI7
Treasury Form A-4
(Revised)
VOUCHER DISTRIBUTION
Description Aotual Size 4 by 8^ inchesj J. page, printed
face only.
Routing Original and two copies as follows: original and
first oopy to Treasury State Accounts Office; second
copy retained by Division of Finance.
Instructions for Preparation See Operating Procedure No. F-21.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix B
Treasury A-5
Form No. A*t(ItaTM)
U. B. TREASURY DEPARTMENT
Aoooumn and Dbpoum
NOTICE OP MISCELLANEOUS ENCUMBRANCE
TO: ACCOUNTANT-IN-CHARGE,
U. S. Treasury Accounts Office,
City and State
Encumbrance No. (Dept.).
Date
Notice is hereby given of the encumbrance authorized
for the amount shown below, which is chargeable to:
Appropriation symbol No..
Appropriation title
In favor of .
For
(Name of Individual or firm)
Location of project .
(Signed)
Transaction code
Appropriation symbol _
Official project No.
Allotment (Works project) No-
Project authorization No.
Treasury encumbrance No.
W. P. A. classification No
Job No
Location symbol.
Type of work symbol
Amount of encumbrance, $—
(City) (County)
— Department or Agency .
(SPACE BELOW RESERVED FOR TREASURY ACCOUNTS OFFICE)
DATE
PARTICULARS
VOUCHER
ENCUMBRANCE
LIQUIDATED
ENCUMBRANCE
AUTHORIZED
UNLIQUIDATED
ENCUMBRANCE
This form to be used in reporting encumbrances for pay rolls, contracts, and other obligations for which no other encum¬
brance document exists. Prepare in quadruplicate and forward original and one copy to the Accountant-in-Charge, Treasury-
State Accounts Office; one copy to the State Administrator, retaining one copy. The Accountant-in-Charge will return one codv
to the issuing officer, indicating thereon the serial number applied by the Treasury-State Accounts Office
Treasury Form A-5
(Revised)
NOTICE OF MISCELLANEOUS ENCUMBRANCE
Description Actual size 8 by lOg- inches; 1 page, printed
face only.
Routing Original and two copies as follows: original and
first copy to Treasury State Acoounts Office; second
copy retained by Division of Finanoe.
Instructions for Preparation See Operating Procedure No. F-30.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. p.
Appendix B
Treasury A-5a
and Uiruiin
CHANGE IN ENCUMBRANCE
(ENCUMBRANCE INCREASE OR REDUCTION)
No
Date
Bureau requisition or encumbrance No. .
Classification or job No
193...
To: ACCOUNTANT IN CHARGE,
U. S. Treasury, State Accounts Office
Request is hereby made for—
Increase I I Cancelation I
Reduction |
for an authorized encumbrance in the amount indicated,
which was charged to appropriation symbol No ...
Appropriation title
Reason for increase, cancelation, or reduction:
Transaction code .......
Appropriation symbol
Group No.
Official project No
Administrative project No
Allotment No. ")
or )
Work project No.J —
District County State .
Objective classification
Treasury encumbrance No
Original encumbrance $...
Increase $...
Decrease or cancelation $...
Net encumbrance $...
Bureau or Department:
(This form used in requesting changes of all encumbrance documents)
Treasury Form A-5a
(Revised)
CHANGE IN ENCUMBRANCE
Description Actual size 8 by lo£ inches; 1 page, printed
"face only.
Routing Original and three copies as follows: original
and first and second copies to Treasury State Accounts
Office; third copy retained by initiating office.
Instructions for Preparation See Handbook of Procedures,
chapter XXI, section 20.
Printed form supplied on request by Works Progress
Administration, Washington, D. C.
Appendix B
Treasury A-6
A coo mm axd Daroam
REQUISITION FOR PURCHASE
From:
193—
(AulbortMd irdmlnlitrstlT* o (Hotel)
(Department or administration)
(City) (State)
To: Procurement Officer, U. 8. Treasurt Dbpt.
It is requested that the items of services or articles listed below
be procured and charged to the appropriation, symbol, and title
indicated.
Symbol Title
(Name, destination addraae)
Date delivery required
PuroboM Order No. ..
Roqulsltlon No
Transaction Code ..
Appropriation Symbol
Official Project No...
Allotment (Work ProJ.) No
Project Aath. Advloe No. ..
cf*Mi?cnU(
Job No. _
Location Symbol.....
Typaof-Work Symbol
Amount of Encambranoe ..
ITEM QUANTITY UNIT
DESCRIPTION 07 ARTICLES (State folly)
ESTIMATED COST
Approved:
(Signature of approving officer)
(Signature of requisitioning officer)
Special approval if required:
Purchase will be made by
Date ...
(Signed) ....
Important.—Purchase orders Issued pursuant to this requisition must show in addition to the information shown in the
upper right-hand block, the above appropriation symbol number and title.
Treasury Form A-6
(Revised 3-1-36)
REQUISITION FOR PURCHASE
Description Aotual sire 0 by 10^ inches; 1 page, printed
face only#
Routing Original and three copies as followst original
and first oopy to Treasury State Aocounts Office; second
oopy to Division of Finance; third oopy retained by
initiating officer.
Instructions for Preparation See Handbook of Procedures,
chapter XX, section 1.
Printed form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
57212 0—38 18
Appendix B
Treaeury A-7
U. B. TBKAB^R?1 DKPARTMINT
AOCOUMTI AMD D*TOUTS
PURCHASE ORDER
From:
(Procurement Offloer)
(City) (State)
To:
(Name of contractor)
Address
You are hereby authorized to ship the following in accordance
with your proposal of
(Date)
Appropriation to b« charged with Vouchers Payable under this Order:
Symbol Title —
Shipping instructions:
193
Purchase Order No. .
Req. No
Official Project No. .
Allotment W. P. No.
For Use of Treasury Department
Location Symbol —
Type of Work Symbol
Appropriation Symbol
Check Symbol
i Urn No.
Description
Number of
Units
Unit
Unit Price
A^oun.
Total,
ProcuTtmmt OJUcr.
Treasury Form A-7
PURCHASE ORDER
Description Actual size 8 by loj inchesj 1 page, printed
faoe only.
Prepared by State Procurement Officej three copies
routed to State Works Progress Administration.
Appendix B
Treasury A-7a
FORM A-7-a
U.S; TREASURY DEPARTMENT
OFF I c£ OF COMMISSIONER OF ASSIGNMENT ORDER
ACCOUNTS AND DEPOSITS
FROM: DATE: 193
(STATE PROCUREMENT OFFICE)
ASSIGNMENT ORDER
NO. .
REQUISITION NO.
OFFICIAL PROJECT
NO.
ALLOTMENT (W.P.)
NO.
ADDRESS:
IN ACCORDANCE WITH YOUR REQUISITION, THE FOLLOWING EQUIPMENT IS HEREBY ASSIGNED
AT THE RATES INDICATED, PAYMENT TO BE EFFECTED ON PAY ROLL- FORM W PA 506
REQUISITION
ITEM NO.
OWNER
AND ADDRESS
DESCRIPTION OF
EQUIPMENT, INCLUDING
LICENSE NUMBER
NUMBER
OF
UNITS
RATE
PER
HQUB
(PROCUREMENT OFFICER)
Treasury Form A-7a
ASSIGNMENT ORDER
Desoription Actual size 8 by 10j| inches; 1 page, face
only.
Prepared by State Procurement Office; three copies
routed to State Works Progress Administration.
Appendix B
Treasury A-8
0. S. TB*A«UBVi>lpAnTMENT
ACCOUNTS AND DlfOlUT*
RECEIVING AND INSPECTION REPORT
(To be nsod tor mil magpllcm, mstarisT, cqolpmant, and Impersonal ■orrtce#)
State Procurement Officer, U. S. Treasury Department,
Purchase
Order No. _
Official
Project No.
Req. No
Allotment
No
Received:
At
(Rooeivlng point)
193
From.
(Vendor or vendor's scent)
Quantity roeei vod
Description of articles
I certify that the above-described articles have been, received, inspected, and { reiecte^;
' [ accepted.
(Receiving administrative officer)
In case of rejection of materials, state fully the reasons therefor on reverse side.
Treasury Form A-8
RECEIVING AND INSPECTION REPORT
Deeoription Actual size 8 by loj- inches; 1 page, printed
face only.
Routing Original and one oopy, as follows: original to
State Procurement Office; copy to Division of Finance,
Instructions for Preparation See Operating Procedure No. F-22.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.
Appendix B
Treasury A-ll
Faoe and Reverse
Form A-ll
U. 8. TREASURY DEPARTMENT
Accounts and Deposits
(Typewrite name of officer)
Department or
Establishment —
Regional
Office
Signature of officer authorized to sign or certify (1) Advice of Allotment,
(2) Purchase Requisitions, (3) Travel Orders, (4) Pay Rolls, (5) and other vouchers
and obligation documents.*
(Signature)
I certify that the above is the signature of the authorized certifying officer.
(Signature)
(Date) (Title)
• Strike out item* which otBcitr >• not authorUcd to Ifauthorlty to oertlly 1" limiUd to documents under a »poolfle projcot authority. allot
meat or projeot. iueh limitation and any other limitation eball bo indicated. 2—16811
Treasury Form A-ll
SPECIMEN SIGNATURE CARD
Description Aotual size 5 by 3 inches; card, printed face
and reverse.
Routing Five copies as follows: four copies to Treasury
State Accounts Office; one copy retained by State Works
Progress Administration.
Instructions for Preparation See Handbook of Procedures,
chapter XIX, section 6.
Printed form supplied on request by Works Progress Ad¬
ministration, Washington, D. C.
INFORMATION TO BE INSERTED BY U. S. TREASURY STATE ACCOUNTS
OFFICE, COMMISSIONER OF ACCOUNTS AND DEPOSITS
BOND REFERENCE
Date of bond
Surety
Penalty, $—
Specific Certifying Authority:
P. «. IBTT PHHTOT Ufflf 2 16811
Appendix G
Treasury D-63
U. S. T^RAWl'llY4liUPifr/'MICNT
Accounts and Daroaira
PAY ROLL ROUTING SLIP
Regular (I) or Aillustmont (2) »—iToas
(il) (Br.) (Pay roil number)
2. Disbursing
voucher No
8. Requisition or P. 0
9. Treasury
*5. Allotment or
work project
*11. Location symbol
7. Treasury voucher
or ichedule No
*13. Number of names
ReLef (01) )
Perianal «*rvicej { Nonrdief (02) $
Dis. compensation (03) $
Subsistence deductions ( ) )
( ) >
15.
16.
17. ToUl of attached voucher.
18.
19.
20. Encumbrance for Dent pay period >.
. Encumbrance to be liquidated $-—
. Encumbrance adjustment —— $---
TYPE OF PAY ROLL
. WPA work relief 2 Other work rebel 3—
23. Pay period-
DATE
Hour
Time Factor
EUpndTme
Uuud
From
To
12 P.M.
27. Sent to administrative
office for correction
28. Resubmitted to pay roD
30. Released by disbursing
31. Grand total elapsed time..
X
X
PAY ROLL ROUTING STUB
Befulor (1) or Adjustment (2)
(St.) (Br.) (Pay mil number)
7. Schedule No. Disbursing you. No, „
32. Received in disbursing office—
33. Cbecks completed by D. 0. ready for dial
34. Pay roll returned to accounts office
Treasury Form D-53
(Revised)
PAY ROLL ROUTING SLIP
Description Actual size 4 by 10^- inches; 1 page, printed
face only#
Routing Original and two oopies, as follows: original and
fi'rat copy to Treasury State Aocouirts Office; second
oopy retailfed by Division of Finance.
Instructions for Preparation See Operating Prooedure No. F-14.
Printed form supplied on request by Works Progress Admin¬
istration, Washington, D. C.