Requisition for Supplies, Equipment, Forms, Publications and Procurement Services	U.S. Department of Housing and Urban Development

Shaded Areas for Services Use Only	2. Posted By:	3. Control No:
Supply Source: Fed. Supply Schedule Open Market Fed Strip GSA Other Govt. Agency FSS Commodity Group No: Local Agency Acct.	4. Processed By: 6. GSA Contract No:	5. Estimated Delivery Date: 7. HUD Purchase Order No:
8. Mail Invoice to:	9. Vendor:
10. Appropriation Code:	11. Sub-Object:	14. Authorizing Funds Control Official: (signature & date)
12. Organization Code:	13. Amount Reserved:
15. Description	16. Quantity	17. Unit of Issue	18. Est. Price Per Unit	19. Est. Total Cost	20. Action Code
Total >>>
21.Clearance Office Code	Deliver To:
Initial and Date:
Authorized Requesting Official: (signature, title, phone, org. corresp. code) & date Title: ; Phone: ; Org: ; Corresp. Code: ; Date: X	24. Received by: (signature & date)