SFN 471, "Vendor payment (TANF) Authorization and Request for Payment of Goods and Services 400-19-165-90

(Revised 6/1/10 ML #3218)

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SFN 471, Vendor Payment (TANF) Authorization and Request for Payment of Goods and Services, is to be used where payment is made directly to a vendor. Directions for completing the form are as follows:

 

Section I. Vendor Information:

• List the name, address, and telephone number of the Vendor who provided the service.
• List the name and address of the TANF recipient who received the services.
• List the date the service was provided, a description of the items or services and the amount claimed.  Once all are listed, enter the Total Amount Claimed.

 

Section II.  Client Information:

• List the TANF recipient’s name, case number and social security number.

 

Section III.  Authorized Agency (County/Contractor Information)

• The person (Employment Contractor, County Director or a Designee) must sign who authorized payment of the service provided must sign, date, and list the name of the agency for whom they work.  

 

Section IV.  State Information:

• This is for State Office use only.

 

Upon completion of the form, send to the state office for processing.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (84kb pdf)

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader.  If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.