Payment Request Form (School Forms) printable pdf download

Payment Request Form (School Forms)

PAYMENT REQUEST FORM

Make Payment To: ______________________________________________ ID #: _____________________

(Use Full name: Last, First, Middle)

(UVA student ID, or Faculty/Staff Employee ID, or Non-UVA last 4 of Soc #)

Today’s Date: ____________________

Date of Event: __________________________

SUBMITTED BY:

_______________________________________________________

Purpose and Location of Event: _______________________________________________________

TOTAL Amount*: _______________

Program/Task: _______________

*If more than one program, please specify amounts below:

Category: _______________________

Amount _________ PTAO_________________________

(expense type)

Amount _________ PTAO _________________________

Detail: _________________________

Amount _________ PTAO _________________________

Please check one:

Breakfast

Lunch

Dinner

Other ___________________________

Total Number of Students/Faculty Attending: _______________

NAMES OF THOSE ATTENDING (IF MORE THAN SIX (6), LIST ONLY OUTSIDE VISITORS BY NAME.

LIST OTHERS BY CATEGORY AND NUMBER (i.e., 15 Students, faculty, & staff).

_____________________________________________ _____________________________________________

If request for reimbursement is over 30 days, please list reason why:

________________________________________________________________________________________

(tape receipts to the back or continue on a full size paper and attach)

ATTACH ORIGINAL RECEIPTS BELOW

PROGRAM APPROVAL SIGNATURE __________________________________________

BIMS wedge\Forms\Pmts & Orders\Payment Request Form updated 12-2011.doc

Payment Request Form (School Forms)