STATE OF CALIFORNIA

CONTRACT/DELEGATION PURCHASE ORDER
STD 65

** sample ** sample **

AGENCY BILLING CODE

CONTRACT/DELEGATION NO.

PAGE OF PAGE
1 | _______

SHIP TO:
AGENCY’S NAME, ADDRESS,
INCLUDING CONTACT NAME AND
PHONE NUMBER

BILL TO:
AGENCY’S NAME
BILLING ADDRESS

DATE (MONTH, DAY, YEAR)

AGENCY ORDER NUMBER

VENDOR: THIS NUMBER MUST BE SHOWN ON INVOICE.

TO
FIRM
ADDRESS

SUPPLIER’S BUSINESS NAME
ADDRESS
CONTACT NAME AND PHONE NUMBER

COMPLETE ONLY
WHEN TO BE USED AS VENDOR’S INVOICE

I hereby certify that this is a true and
just bill and payment has not been
received.

VENDOR’S INVOICE NUMBER

(Type or Print Legibly)

VENDOR’S SIGNATURE

TITLE (OWNER, MGR., CLERK, ETC.)

VENDOR NUMBER

S / B

ETH8

VENDOR’S TAXPAYER ID NUMBER (FEIN)

NOTICE TO MERCHANT

1. Show the Agency order number and Contract/Delegation number on your invoice.
2. Show cash discounts offered on your invoice.
3. Submit invoice in triplicate. If not on printed bill head, vendor please sign invoice.

4. Vendor’s Federal Employer Identification Number is required.
5. Submit original receipted expense bills if your invoice includes prepaid transportation charges.
6. All shipments shall be F.O.B. destination unless other wise stated on this order.

DATE WANTED

SHIP VIA

TERMS

ITEM NO.

QUANTITY

UNIT

COMMODITY CODE

DESCRIPTION

UNIT PRICE

EXTENSION

1

1,000

EA

COMPUTER WORKSTATIONS

1,200.00

1,200,000

Per the attached Supplier specifications

THE INFORMATION IN THE COLUMN TO THE RIGHT IS CRITICAL; IF IT IS NOT ON THE PURCHASE ORDER AS SHOWN, THE STATE CONTROLLER’S OFFICE WILL NOT ISSUE PAYMENT TO THE LESSOR. DON’T FORGET TO ATTACH THE ENTIRE AWARDED LESSOR’S RFLQ TO THE PURCHASE ORDER ALSO.

The Terms and Conditions found in the State’s financial marketplace, Lease $Mart, Version _________ dated _______, and the Lessor’s attached Request for Lease Quote (RFLQ) and its provisions, dated _______, are hereby incorporated into and made a part of this purchase order hereto. The State designates (LESSOR’S NAME) as its Lessor for this contract. The Lessor will pay the Supplier for assets/services on behalf of the State. The Lessor is entitled to all payments owed pursuant to the Lease Payment Schedule in consideration for the Lessor’s payments of the cost of the assets to the Supplier.

Lessor’s Business Name
Business Address
Contact Name and Phone Number

Term: (i.e., 36 months) _________

2

1

EA

Required Data >

Lease Charges (Per the attached RFLQ)

$203,596.96

$203,596.96

Any other required information for the purchase order…

FOB

Sales tax is not included on the PO— this cost is reflected in the RFLQ as a use tax.
>

SALES TAX
7.75%
$ 0.00

CHARGE AGAINST

PROGRAM CATEGORY (CODE AND TITLE)

FUND TITLE

(OPTIONAL USE)

TOTAL $1,403,596.96

ITEM

CHAPTER

STATUTE

FISCAL YEAR

OBJECT OF EXPENDITURE (CODE AND TITLE)

 O.E  EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY. On my own personal knowledge that this order for the purchase of the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California that all such legal requirements have been fully complied with.

ENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT INCREASING ENCUMBRANCES

TITLE

ADJUSTMENT DECREASING ENCUMBRANCES

SIGNATURE

CERTIFIED CORRECT (SIGNATURE)