Check Request Form - University Of Washington

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UNIVERSITY OF WASHINGTON
Vendor Code
CHECK REQUEST
RESET BUTTON
ACCOUNTS PAYABLE, BOX 351130
Reason for Payment
Service Date or Period
Transaction Code
Reimbursement (Attachments Required)
50
Honorarium (Details listed below)
Other
Department Name
Department Contact
Department Phone
Tech Contact
Tech Phone
Box Number
STATUS (required)
U.S. Taxpayer ID Number
1099 Type
Privacy Act Notice: IRC Section 6109 requires most recipients for services performed to give
taxpayer identification numbers to payers who must report the payments to IRS. IRS uses the
U.S. Citizen
numbers for identification purposes. Payers must be given the numbers whether or not recipients
Non-Resident Alien
are required to file tax returns. Payers must generally withhold taxes from taxable payments to a
Resident Alien
payee who does not furnish a taxpayer identification number to a payer. Certain penalties also apply.
1. Vendor/Claimant Name
2.
3. Permanent Address
4.
VENDOR’S CERTIFICATE: I hereby certify that the items and
totals listed herein are proper charges for materials, merchandise
or services furnished to the University of Washington.
5a. City
State
Zip
Signature
5b. Country (Foreign)
Date
Check Handling Instructions
Special Instructions
Mail to Permanent Address
Hold for Pick-up: Call
Phone
3. c/o
Send to:
4. Box
Detailed Description of Business Purpose of Expense (Required)
Quantity
Unit
Unit Price
Extended Amount
SUBTOTAL
CHECK
LESS W/H
AMOUNT
ACCOUNTING DETAIL
S
L
FUND
GENL LDGR
COST ACCOUNTING ONLY
INVOICE/
DATE
USE TAX
AMOUNT
I
REFERENCE
/
PREPARED
BUDGET
OBJ SUB SSUB TASK OPTN PROJECT
NUMBER
L
Q
NUMBER
N
N
N
N
N
Preparer’s Signature
Authorizing Official’s Signature
Check Number
Date Signed
Date Approved
Check Date
UoW 1570 (Rev.7/09)

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