Complete the top portion of this form and return it to:
Office of the State Comptroller
Bureau of State Expenditures
Knowledge Management Unit
Albany, NY 12236
FAX: (518) 473-3380
Agency Name: _______________________________________________________________
Agency Code: _______________________________________________________________
Types of Refunds
Issued by Agency: ____________________________________________________________
and Title : ___________________________________________________________________
with Area Code: ______________________________________________________________
The following information will be required at a later time.
A. Name and operator ID's of persons to certify:
NOTE: These certifiers must be authorized to sign vouchers, in accordance with Section 110 of the State Finance Law, and must be on file with OSC Knowledge Management Team.
B. Names and operator ID's of persons to enter Quick Pay Refund
C. Description of types of refunds issued by the Agency.
D. For each type of refund issued, list the coding (dept., cost center,
var., yr., object) used on the original Report of Moneys Received or
cc: Bureau of Accounts