Header and deposit instructions
Disbursing office number, bureau voucher number (paying office), a Paid By box, and the instruction to deposit and send the accomplished C/D, or to send a remittance.
GSA789
Statement, Voucher and Schedule of Withdrawals and Credits
- Agency
- GSA
- Revision
- Rev. 10/1973
- Fillable fields
- 156
- Pages
- 1
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 789: Statement, Voucher and Schedule of Withdrawals and Credits
GSA Form 789, Statement, Voucher and Schedule of Withdrawals and Credits, is a General Services Administration form, GSA Form 789 (Rev. 10-73), hosted in GSA's forms library. Its header asks the office billed to deposit to the credit of the account(s) shown and send the accomplished C/D to the office named, or to send a remittance payable to The General Services Administration, with one copy of the form, to that office.
The statement lists charges by agency requisition number, ACT, GSA invoice or document number, invoice date, amount and remarks, with a total amount due. The lower part is the voucher: the disbursing office and symbol paying office, the department, bureau and address to withdraw from, the bureau reference, the appropriation or fund symbol and amount, and a certificate of paying office signed by an authorized certifying officer.
The form says adjustments are not to be requested or made for over or under charges of $10.00 or less per line item. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 789
Statement details
Date, page number, statement number, agency and billed office codes, and the office billed with its ZIP Code.
Line items
Agency requisition number, ACT, GSA invoice or document number, invoice month and day, amount and remarks.
Total amount due
The total on the statement, which the form says must be paid as rendered in accordance with 7 GAO 2. 8.5 and FPMR Title 41 Chap. 101.
Withdrawal voucher
To (disbursing office and symbol paying office), withdraw from department, bureau and address, bureau reference, appropriation or fund (symbol only) and amount.
Certificate and payment record
Certificate of paying office with date and authorized certifying officer, then Paid By with check number, date, C/D number and date.
How GSA Form 789 is completed
- 1
Enter the statement details
Fill in the date, page number, statement number, agency and billed office codes, and the office billed.
- 2
List the charges
Enter each line item with its requisition number, ACT, invoice or document number, invoice date and amount, then the total amount due.
- 3
Complete the withdrawal block
Enter the disbursing office and symbol paying office, the department, bureau and address, the bureau reference, the appropriation or fund symbol and the amount.
- 4
Certify for payment
The authorized certifying officer certifies that the items are correct and proper for payment from the appropriation(s) designated, and dates it.
- 5
Deposit or remit
The form says to deposit to the credit of the account(s) shown and send the accomplished C/D, or send a remittance payable to The General Services Administration with one copy of the form.
- 6
Record the payment
The Paid By line at the foot takes the check number and date and the C/D number and date.
Why fill Form GSA789 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the GSA, not a copy someone retyped
- Works on a phone, tablet or computer
What the form says
Where it goes
To the office indicated in the deposit block. The form prints no fixed address.
Referencing a payment
The form says payment or inquiry should refer to the date, statement number, agency and billed office codes for prompt handling.
Adjustments
The form says adjustments are not to be requested or made for over or under charges of $10.00 or less per line item (FPMR - A - 101-2.104(c)), and that adjustments, if required, will appear on subsequent statements.
Edition and authority
The header reads GSA Form 789 (Rev. 10-73) and the foot prints 7789-105. GSA's page gives a current revision date of 10/1973 and lists no authority or regulation.
Instructions
The PDF prints no instructions beyond these notes, and no OMB number or privacy statement.
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Who uses GSA Form 789?
The form prints no instructions on who prepares it. Its blocks name these offices and roles.
Official sources and the blank
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Questions about Form GSA789
Who issues GSA Form 789?
The header reads GENERAL SERVICES ADMINISTRATION and GSA Form 789 (Rev. 10-73). GSA hosts it in its forms library.
How is a GSA Form 789 statement paid?
The form says to deposit to the credit of the account(s) shown and send the accomplished C/D to the office indicated, or send a remittance payable to The General Services Administration with one copy of the form.
Can small over or under charges be adjusted?
The form says adjustments are not to be requested or made for over or under charges of $10.00 or less per line item.
What should a payment or inquiry refer to?
The date, statement number, agency and billed office codes shown on the statement, which the form says is for prompt handling.
Who certifies the voucher?
An authorized certifying officer of the paying office, who certifies that the items are correct and proper for payment from the appropriation(s) designated.
Does GSA Form 789 have instructions?
Only the printed notes on the form. It has no OMB number or privacy statement, and GSA's page lists no authority or regulation.