Non-Employee Invoice Form
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1UH Form NE-INV (Disb)
Clear Form
Rev. 9/15/00
Non-Employee Invoice
UH Department: _______________________________________________________ Invoice Number: ____________________
Billing Address: _______________________________________________________ Purchase Order Number: _____________
Part A: Complete the following information
Legal Name/Taxpayer ID:
/
Last or Family Name
First Personal Name
Middle initial
U.S. Social Security Number or Taxpayer ID
Remittance Address:
Number and Street
City or Province
State or Country
Postal Code
Are You an U. S. Citizen?
Yes, I am an U. S. Citizen. No WH-1 Required.
No, I am not an U. S. Citizen. I have attached a WH-1 and all other documentation as
required for tax status determination.
Part B: Date(s)/Description of Services Performed and/or Date(s)/Purpose of Travel
Part C: Recordation of Expenses
FEE FOR SERVICES RENDERED: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
HONORARIUM PAYMENT: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
MEALS,LODGING & INCIDENTAL EXPENSES: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
MEALS & INCIDENTAL EXPENSES ONLY : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
LODGING EXPENSE ONLY :
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
MILEAGE:
$
____________
X
$____________/Mile
= . . . . . . . . . . . . . . . . . . . . . . . . .
0.00
(Total Miles)
(Mileage Rate)
OTHER EXPENSES:
Airfare
= . . . . . . . . . . . . . . . . . . . . . . . .
$
Car Rental
= . . . . . . . . . . . . . . . . . . . . . . . .
$
= . . . . . . . . . . . . . . . . . . . . . . . . .
$
= . . . . . . . . . . . . . . . . . . . . . . . . .
$
0.00
$
TOTAL AMOUNT DUE: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
art D: Certification of U.S. Citizenship
P
I certify that I am a U.S. Citizen. I further certify that the U.S. Social Security or Taxpayer ID Number shown above is correct
and that I am not subject to backup withholding.
Original Signature
Date
********************Fiscal Office Use Only*********************
Account Information for Data Entry
Account Code
Subcode
Amount
Account Code
Subcode
Amount
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Parent category: Business