/ Directions of the Minister / Capital Works Payment Claim Form
DHS use only
Capital Management / Project Endorsement / Payment Authorisation
Capworks ID
...... / ......
Project Manager
...... / $ ......
Amount (including GST)
Date: ...... /...... / 200 / ......
Authorising Officer (Print)
Capital Management Branch
......
Signature
Capworks
Entered / Signature / I certify that this amount is true and correct in respect of the requirements of the Directions of the Minister under the Financial Management Act 1994
Agency/Claimant: / Vendor No.
Vendor Site
Postal Address:
Project Name:

Payment Details: Finance Officer, Capital Management Branch and Financial Services Branch, DHS

Claim / Invoice Date / Claim / Invoice Number / Financial Year 2005 / 2006
Entity / Activity / Account / Identifier / Amount
Cost Centre / Fund / Prod
2 / 4 / 5 / 3 / 5 / 2 / 5 / $ / c
1 / 0 / 0 / 0
1 / 0 / 0 / 0
1 / 0 / 0 / 0
1 / 0 / 0 / 0
1 / 0 / 0 / 0
Payment Confirmation: Financial Services Branch, DHS / Payment Certification: Financial Services Branch, DHS
I certify that I have checked this account in accordance with the Directions of the Minister under the Financial Management Act 1994. / I certify that this account is true and correct in respect of the requirements of the Directions of the Minister under the Financial Management Act 1994.
Signature of Officer ………………………………………………………
Position Title ………………………………………………………………
Date / Certifying Officer ……………………………………………………………
Position Title ………………………………………………………………
Date
Certification: Manual Cheques only
I certify that a “not negotiable” cheque for the amount below has been forwarded to the claimant.
Authorised Paying Officer, DHS / Amount $
Cheque No. / Date / / 200
Signature of Payee