W 1270 Form PDF Details

In the diverse landscape of forms facilitated by the State of Connecticut's Department of Social Services (DSS), the W-1270 form serves as an essential document for vendors aiming to process payments through the department's accounts payable division. Updated last in September 2010, this form is meticulously designed to ensure that all payment requests from contractors and vendors are seamlessly handled, with a clear delineation of the required fields for different contract and purchase types, such as Purchase Orders (POs), Personal Service Agreements (PSAs), and others. It captures comprehensive details, including vendor information, contract periods, payment schedules, and the total contract amount, alongside the specificity needed for DSS verification. The payment request process is intricately outlined, guiding contractors through each step, from identifying the contract type to detailing the authorization process, thereby minimizing errors and speeding up the approval and payment processes. Additionally, the form includes a critical section exclusively for DSS use, ensuring that every payment is in compliance with the contract requisites and that the expenditures are authorized accordingly, emphasizing the form's role in maintaining fiscal responsibility and operational transparency within the state's contracting and payment domains.

QuestionAnswer
Form NameW 1270 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesct dss online fillable forms, amazon, dss form w 35, w 35

Form Preview Example

W-1270

 

 

 

 

 

 

 

STATE OF CONNECTICUT - DEPARTMENT OF SOCIAL SERVICES

 

 

 

 

 

 

 

 

 

 

 

(Rev. 9/10)

 

 

 

 

 

 

 

 

 

 

 

 

REQUEST FOR PAYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSS ACCOUNTS PAYABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voucher #:

 

 

 

 

 

VR Processed by:

 

 

 

 

VR Date:

 

 

 

 

Voucher Approved by:

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYEE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vendor Invoice #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Purchase/Contract Type:

 

 

PO

POS

 

PSA

 

MOA/TI

BOND

 

Vendor/Contractor Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

Competitive

 

 

 

 

 

Non-Competitive

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spending Plan Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORE-CT Contract #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSS Contract #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PO #:

 

 

 

 

 

 

 

 

 

 

 

 

Receipt #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEIN #:

 

 

 

 

 

 

 

 

 

 

 

 

Vendor #

 

 

 

Remittance Address: (where the check is to be mailed – YOU MUST FILL THIS IN)

Contract Period:

 

 

 

 

From:

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payment Period:

 

 

 

 

From:

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Contract:

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Previous Payments:

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This Payment:

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program is operating in compliance with Contract and expenditures have been incurred accordingly.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorization:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contractor Name (print)

 

 

 

 

 

 

 

 

Contractor Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DON’T FILL IN BELOW – THIS IS FOR DSS USE ONLY:

 

DSS PROGRAM VERIFICATION – If multi funding source, provide all appropriate accounts.

 

 

 

 

 

 

 

 

 

 

 

Budget

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount

 

Reference Fund

 

Department

Program

 

SID

 

Account

 

 

 

 

 

Project/Grant

 

 

Chartfield 1

Chartfield 2

 

$

 

 

 

 

 

 

 

 

 

20

 

 

 

 

DSS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

168

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

20

 

 

 

 

DSS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

168

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

20

 

 

 

 

DSS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

168

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

20

 

 

 

 

DSS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

168

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

20

 

 

 

 

DSS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

168

 

 

 

 

 

 

 

I do certify that this program is operating in compliance with Contract and expenditures are authorized and properly chargeable as indicated. Authorization:

DSS PROGRAM STAFF REP - Name (print & sign)

 

 

 

Date

Phone #

 

 

 

 

 

 

 

 

 

 

 

 

*Financial Report Required

Yes

No

Co-sign (if required) Signature

Phone #

 

 

 

 

 

 

*Financial Report within last 3 mos.

Yes

No

 

 

 

 

*Attach Explanation If Report Is More Than 3 Months Old

DSS FISCAL STAFF APPROVAL - Name (sign & date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUEST FOR PAYMENT FORM PROCEDURES

DSS Accounts Payable

This section should be completed by the Accounts Payable staff reviewing the requisition. Incomplete requests received by AP will be returned to the DSS representative authorizing the payment request and will result in a delay in payment.

Contractor, Contract & Payment Information

NOTE: If Payment Request is a Purchase Order (PO), please fill in the fields indicated below. All other requests, fill in entire form.

Contractor Name & Address

(PO) Enter the contractor's full name and complete address (with areas for both Business and Remittance addresses)

Vendor Invoice #

(PO) Enter the contractor's invoice number if available

Authorization

Enter the authorized contractor's name, date of completion of request and signature of authorized individual

Purchase/Contract Type

(PO) Check the appropriate contract type (POS, PSA, MOA/TI, BOND, or PO for non-contractual items)

Spending Plan

Enter the applicable spending plan program code if the item is on a spending plan (BAS, ECE, etc.)

Finalize PO

(PO) Indicate whether the remaining encumbered funds are to be decommitted after the payment is made.

Old Contract #

Enter the old contract number for which the payment is requested

Core-CT Contract #

Enter the complete CORE-CT contract number for which the payment is requested

PO #

(PO) Enter the CORE-CT purchase order number for which the payment is requested

Receipt #

(PO) Enter the CORE-CT Receipt # upon entering the receipt into the CORE-CT system.

FEIN #

(PO) Enter the complete federal employee identification number

Contract Period

Enter full contract period

Payment Period

(PO) Enter the period for which the payment is requested (if deliverable based, this can be left blank)

Total Contract Amount

Enter the total amount the program/contract was approved for

Previous Payments

Enter the total amount of payments already received against this program/contract

This Payment

(PO) Enter the amount of funds that are being requested for the above identified payment period

DSS USE ONLY -

DSS Program Verification

This section should be completed by the regional or program staff responsible for payment authorization. For contracts which are based in the regions, a CO program staff should co-sign the request to verify that no spending plan changes have been made that would affect the payment.

Amount

(PO) Indicate the funding allocation associated with each accounting string (consistent with the spending plan)

Budget Reference

(PO) Enter the CORE-CT budget year designation (formerly 7th digit of SAAAS Activity code)

Fund

(PO) Enter the CORE-CT fund code (refer to CORE-CT coding specifications)

Department

(PO) Enter the CORE-CT department code (refer to CORE-CT coding specifications)

Program

(PO) Enter the CORE-CT program budget code (refer to CORE-CT coding specifications)

SID

(PO) Enter the CORE-CT SID code (refer to CORE-CT coding specifications)

Account

(PO) Enter the CORE-CT account code (refer to CORE-CT coding specifications)(formerly SAAAS Object code)

Project

(PO) Enter the CORE-CT project/grant code (refer to CORE-CT coding specifications)

Chartfield 1

(PO) Enter the CORE-CT Chartfield 1 code (refer to CORE-CT coding specifications) spending plan designation

Chartfield 2

(PO) Enter the CORE-CT Chartfield 2 code (refer to CORE-CT coding specifications)

Authorization

Enter the authorized individual's name and date of completion along with signature indicating contract compliance

C.O. Co-Sign

For contracts based in the regions, CO program staff should co-sign the request to verify that no spending plan

 

changes have been made that would affect the payment

Financial Report Required

Check Yes or No to indicate whether or not a Financial Report is required for this contract

 

Check Yes or No to indicate whether or not a Financial Report is less than 3 months old

 

Attach explanation if report is more than 3 months old

CORE-CT CODING SHEET

IF ADDITIONAL CODING LINES ARE REQUIRED USE

Original Coding String:

SID

 

Function

 

Object

 

Activity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coding String:

 

 

Budget

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount

 

Reference Fund

Department

 

Program

 

SID

 

Account

 

Project/Grant

 

Chartfield 1 Chartfield 2

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

$

 

20

 

 

 

DSS

 

 

 

 

 

 

 

DSS

 

168

 

 

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