PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL
;
svired ocfobsr 1987
sparmmt of
Tr.a.r"
TFM 4.~000
034121
me
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-..kS~DEPAflTMENT,BUREAUrORESTABLISHMENT-AND LOCATION-
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ATLYO CH
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'F lOlst ABN, IBCT
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CONTRACT NUMBER AND DATE
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PAID BY
DSSN:8589
Adan Butler, MAJ
101st FMC
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REQUISITION NUMBER AND DATE
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PAYEE'S
NAME
AND
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: D A E INVOICE RECEIVED
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PaYEE'S ACCOUNT NUMBE
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4IPPED FROM
TO
:
WEIGHT
QVSRNMENT
BIL NUMBER
Property Damage
U w cmtinvati~nh s
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'AYMENT:
PRDVlSlONA
TJ
7
COMPLETE
7
7
PARTIAL
FINAL
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PROGRESS
7
ADVANCE
=$
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2,400.00
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BY'
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TITLE
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lrsuant to authoti
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CPT, FCC:
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ACCOUNTING
CUSSIFICATION
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162020 22-0204 P436099.22-4200 VlRQ F9203 S99999 APC 9204
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KECK
NUMBER
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DATE
s 2,400.00
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Whsn s f a t ~ din foreign cunency. insert nams of sunenc".
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SMALL CLAIMS CERTIFICATE
SLMMlT IN TRIPLICATE
For use 01 this form. see AR 27-20: the oranoncnt eocnov Is the Office of the Judoe Advocate Generd.
IRGANIZARON.OF-INVESTIGATOR
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F l O l s t ABN, lBCT
6-IA3-026
ADORESS UneIude ZTP CmW
T i t , Iraq
IAME OF CLAIMANT
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NO
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II
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X
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DOCUMENTARY EVIDENCE EXAMINED
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CLAIMANTINTERVIEWED
SECTION I - ACTION TAKEN BY INVESTIGATOR
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I have investigatedk incidelu descrZbed in the claim as follows:
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ITEM
PROPERTY DAMAGE EXAMINED
SCENE OF INCIDENT VISITED
YES
WITNESSES
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INTERVIEWED
II
METHOD OF INTERVIEW
(Pcmnnl, zrlep4one. or
NAME
7--
ITEM
NAME
mrre(pndence1
METHOD OF INTERVIW
IPermM1, frelp4one, or
mrmpDdence)
I
OMMENTS OF INVESTIGATOR:
Ifind that t h e e v i d e n c e substantiates t h e c l a i m a n d t h a t t h e a m o u n t c l a i m e d or a g r e e d qmn
constitutes f a i r c o m p e n s a t i o n for the d a m a g e i n c u r r e d by claimant. Ir e c o m m e n d p a y m e n t
of $2,400.00
u n d e r Chapter 3 0 , 4 U . 5 0 . 6 0 . 7 0 , 10m. 1 2 0 , AR 27-20.
A f t e r d u e consideration, Ih a v e d e t e r m i n e d t h a t t h i s c l a i m i s m e r i f o r i o u s a n d i s c o g n i m b l e u n d e r
, AR 27-20; t h e c l a i m a n t is a p r o p e r claimant; a n d a n a w a r d of $2.400.00
is
C h a p t e r 10
reasonably substantiated.
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APACITY OF OFFICER
, C P T , FCC
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A FORM 1668, JUN 71
REPLACES DA FORM 1668. 1
1
Claims Form
Hometown:-
-13 Iraqi Residen::
7-ikf4-
My claim arose at:My claim arose on:
(Town)
0Month
(city)
I<
5
Day
(Country)
Year
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11th
Proof of Ownership:
0 Interpreter Approved:
V"L'T
Death Certificates (Name, Cause of Death, Age, and Time of Death Consistent with Claimant
allegations): Vp/,
d5 Dr-c
-e&d
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0 Interpreter Approved:
Legal Expert Opinion:
Interpreter Approved:
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Witness Statement (Consistent?):
U Interpreter Approved:
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Give a brief statement of the accident or incident on which the claim for damages to property or for
personal injury is based. (Use back of this sheet if necessary.)
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List in detail the amount of property damage and itemized expenses resulting from the property
damage or personal injury: (Attach bills and receipts, if applicable.)
Amount
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dcaoc,.
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00
dowbC
1 was insured to the following extent against the damage or injuries I have sustained.
The name and address of my insurer (if any) is:
(Name)
(Address)
I claim as damages: (Indicate amou
$-
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Subscribed before me this
3day of
(Signature)
I\rw
,200s
"