Appendix K

Appendix K version 6/25/97

Multiple Object Class Code/ Functional Management Code (FMC) Reconciliation Form

Instructions: If the Object Class Code or FMC for purchases differs from the MR's "generic" class codes. Print this form and complete the following. Return this form with your reconciled Statement of Account toGG-B1-A for payment.

Cardholder Name: Mail Code:

Phone: Fax:

Credit Card Number:

Date of Statement:

Object Class Code Functional Management
Code (FMC)
Approved Amount $ Comments (Optional)

_______________ _______________ _______________ _______________

_______________ _______________ _______________ _______________

_______________ _______________ _______________ _______________

_______________ _______________ _______________ _______________

Total of Statement to be paid:________________________

		Appendix K version 6/25/97
	Multiple Object Class Code/ Functional Management Code (FMC) Reconciliation Form

Cardholder Name:	Mail Code:
Phone:	Fax:
Credit Card Number:
Date of Statement:

Object Class Code	Functional Management Code (FMC)	Approved Amount $	Comments (Optional)
_______________	_______________	_______________	_______________
_______________	_______________	_______________	_______________
_______________	_______________	_______________	_______________
_______________	_______________	_______________	_______________