Advance Request And Settlement Agreement Form - The University Of New Orleans
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1Advance Request and Settlement Agreement
Name _________________________ Date _________ Employee ID # ___________________
REQUIRED
Last name, first
Address _______________________ City _______________ State __________ Zip _________
Department __________________________ Position __________________
Purpose of Advance _________________________________________________________________
Date advance needed ________________
Call for check pickup ___________________
Extension
Advance Requested $ __________________
This advance will be cleared by an Advance Clearance form. This is not intended for Travel Expenses.
Complete the chart below with the main account to be charged when Advance Clearance form is turned in.
Is this to be charged to a grant? ______ Yes _______ No
Account
Speed Type/
Account
Department
Amount
Fund
Program
Project/Grant
Number
Chart
Number
ID
$
OR
130091
130091
Settlement Agreement
I acknowledge receipt from Accounts Payable of ____________________ dollars as an advance for the cost of
the above described purpose. I agree to settle this advance by filing an Advance Clearance Form with the office of
Accounts Payable (with attached receipt of any unused funds returned to the Bursar) on or before
_____________________ (due date).
(within 15 days of event date )
If I have not settled this advance with the office of Accounts Payable by the due date, I hereby authorize the
University of New Orleans to deduct the full amount from my first paycheck following the due date or any subsequent
paycheck.
_________________________________
__________________________________________________
Signature of Payee
Date
Approval of Dean, Chair or Department Head
Date
Checks can only be picked up by the payee unless name given here_______________________________
Designated recipient will need Staff Identification to pick up check.
Approval of Accounting Services ______________________
Advance picked up by ________________________________
This form should be routed from the department to Accounting Services and then to Accounts Payable for
processing. Checks will be ready for pickup ten days after receipt in Accounts Payable.
Rev 10/09
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