Filing a Claim with the State of Connecticut

Subscriptions, Memberships and Dues Payments

• Policies
• Instructions for the Health Center Invoice (Vendor Payment Voucher) Form CO-17 For Subscriptions, Memberships and Dues Payments

Departments requesting payments for subscriptions to magazines, journals, books, newspapers, license renewals, fees, etc., or for memberships and dues under $10,000.00, must complete a Health Center Invoice (Vendor Payment Voucher) Form CO-17 (PDF).

Advertisement charges, $2,000 and over, requires a purchase order and will be processed through the Purchasing Department

Note: For subscriptions, memberships and dues $10,000 AND OVER, a "Purchase Requisition" must be used and processed through the Purchasing Department.

The business purpose and benefit to the Health Center's program should be explained, in terms that a lay person would readily understand.

The original and one copy of the literature from an organization indicating cost of membership, or a notice of renewal, or cost of a subscription, must be submitted with the Health Center Invoice (Vendor Payment Voucher) Form CO-17.

All payment requests must be submitted to the Health Center's Accounts Payable Office (MC 4031) for processing. The payment will be mailed directly to the publisher, vendor or organization from the General Accounting Office.

Follow the instructions to complete a Health Center Invoice (Vendor Payment Voucher) for all payment requests.

Note: Department name, mail code and telephone number must appear on all forms.

Send the completed Health Center Invoice (Vendor Payment Voucher), with the following documents attached, to the Accounts Payable Office (MC 4031):

• Original and one copy of the literature from an organization indicating cost of membership, or a notice of renewal with it's return envelope, or
• Original and one copy of the subscription invoice or renewal notice.

Note: For new subscriptions, dues and memberships please fill in the form completely.

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Please fill in the following information on a blank Health Center Invoice (Vendor Payment Voucher) Form CO-17 (PDF).

(A) DOCUMENT DATE
Date that this CO-17 is prepared (MM/DD/YY).

(B) DOCUMENT NO.
Each Department should keep a listing of their own unique 7 digit numbers. Care should be taken to ensure that each form has a different consecutive number.

(C) RECEIPT DATE
Date goods and/or services are received or, in certain instances, the date payment is contractually due (MM/DD/YY).

(D) P.O./ P.S.A. NO.
Reference original Commitment Document for Commitment Number, if any (i.e. Purchase Order Number or Personal Service Agreement Number).

(E) RPT. TYPE
Leave blank.

(F) VENDOR FEIN/ SSN
List Federal Employer Identification Number or Social Security Number. If multiple listing (Form CO-17L) is being used, do not complete this block.

(G) DOCUMENT AMOUNT
The subscription, memberships and dues amount to be paid. The Document Amount in Block K must be equal to the Expended Amount in Block U or Block G (Document Amount) will read "false".

(H) VENDOR / PAYEE
The Vendor's full Name and Address.

(I) VENDOR BILLING INFORMATION
Vendor Invoice Number, Grant Payment Code, or other vendor information. This identification will be printed on the check which enables the vendor to identify the payment.

(J) DESCRIPTION
Description of Goods and/or Services completed. (Include business purpose for this expense.)

(K) AMOUNT
Number of Units times the Purchase Price for each item.

(L) CHECK DUE DATE
Date check must be written.

(M) ENCLOSE ATTACHED DOCUMENTS WITH CHECK
[ ] YES [ ] NO

Note: Any documents that are to be enclosed with the check must be duplicated, the original and one copy must be sent along with the invoice for payment.

(N) ENCLOSURE CODE

• "D" - Document to be mailed to vendor with the check.
• "G" - Check to be picked up at the Bursar's Office by Department.

(O) CHECK TO BE PICKED UP AT BURSAR'S OFFICE
[ ] YES [ ] NO

(P) PERSON TO CALL
Name and Phone Number of Person to call when check is ready.

(Q) JUSTIFICATION FOR PICK UP
Checks are not routinely returned to the department for mailing. Therefore, there must be valid justification for a representative of the department to pick up the check rather than having it mailed out directly to the vendor. The individual picking up the check must have proper identification.

(R) LEDGER NUMBER
A one (1) digit number.

(S) ACCOUNT NUMBER
A five (5) digit number.

(T) SUBCODE NUMBER
A four (4) digit number.

• For Subscriptions and Dues Combined: use #2130;
• For Dues Only: use #2131;
• For Subscriptions Only: use #2132.

(U) AMOUNT
The amount to be charges to the Department FRS Account.

(V) NAME OF THE DEPARTMENT AND THE DEPARTMENT MAIL CODE

(W) NAME OF THE PERSON AND THE PHONE NUMBER
Phone number and name of the person to contact so that specific questions regarding the contents of this Invoice can be answered.

(X) AUTHORIZED SIGNATURE / APPROVAL
Signature of the Principal Investigator, Department Head, Dean, Director (or authorized designee) indicating approval for payment. An individual listed as Vendor/Payee may not approve his/her own invoice.

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