W 1270 Form – Fill Out and Use This PDF

The W-1270 form, issued by the State of Connecticut Department of Social Services, serves as a Request for Payment to DSS Accounts Payable. This document is crucial for vendors or contractors seeking payment for services rendered or goods provided under specific contracts with the department. If you need to ensure timely and accurate payment for your contract, click the button below to fill out the form correctly.

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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.

Question	Answer
Form Name	W 1270 Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	ct dss online fillable forms, amazon, dss form w 35, w 35

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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:

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

DSS

168

DSS

168

DSS

168

DSS

168

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 Required	Yes	No
		*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)		*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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W 1270 Form – Fill Out and Use This PDF

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