Employee Payment Request Form For Isp/pda Data Connection/business Calls Via Cell Phone Page 2
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2Employee Payment Request Form for
Telecommunications & Internet Service Providers (ISP)
Harvard University’s policy regarding telecommunication payments changed on May 1, 2001,
and now requires additional documentation fulfilling an “accountable plan.” Under IRS
regulations, an accountable plan stipulates the following documentation be collected before
payments can be made: 1) a clear University business purpose, 2) original vendor invoice or
receipt, and 3) an allocation of business vs. personal usage. Payments may only be made for the
portion or percentage of cost specifically allocated to University business. The information
requested on the front of this form will be required with each payment request. When requesting
a GE Corporate Card payment or a reimbursement for your telecommunication costs, please
complete this form and submit it along with a Universal Expense Form (UEF).
Date: Today’s date.
Name: Full name of the employee requesting a reimbursement or payment on his/her behalf.
Business Need: Check all appropriate boxes. If “other” is selected, provide a complete business
purpose.
Number of Receipts: All relevant original vendor invoices, receipts or equivalent
documentation must be attached to this form. Payments will not be processed without original
itemized documentation (e.g. invoices, monthly statements, receipts or a completed Missing
Receipt Affidavit [MRA] with copies of receipts attached). If a vendor bills your credit card
directly, you must contact the vendor and request copies of your monthly statements. Credit
Card statements may not be submitted in lieu of original itemized vendor documentation.
An MRA may be submitted in the rare event that an original receipt was lost or is not available;
however, copies of the receipt must be attached. Itemized ISP services receipts often are
available on-line.
Total Dollar Amount of Attached Receipts: Add the total cost of telecommunication services
you are submitting for payment or reimbursement at this time. Documentation may include
additional unrelated service costs; do not include these items in the totals.
Percentage of HU/SEAS Business Usage of Service During Period: Within the period of service
for which you are submitting a request for reimbursement or GE Corporate Card payment,
indicate the percentage of the total usage that was solely for HU/SEAS business. ISPs, PDAs and
cell phones are often used by employees and family members for non-HU business matters.
Under Harvard/IRS policy, the University is permitted to assume only the portion of
telecommunication costs specifically allocated to University business.
Total Amount Due: Multiply the telecommunication service total for the period by the
percentage of HU/SEAS business usage for the period. This is the total amount that will be
reimbursed to the employee or paid directly to a GE Corporate Card. Employees are
responsible for paying their corporate card accounts for portion of the charges allocated to
personal usage.
Signature: The employee being reimbursed must sign and date the form.
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