Independent Contractor (Ic) Checklist Page 10
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10Independent Contractor
Confirmation of Services Performed
(or Cancellation of Services)
for Multiple Payments
Independent Contractor Name:
Grand Total from Request for Payment
Date(s) of Service(s):
to
Form:
FOR MULTIPLE PAYMENTS ONLY: Please complete payment schedule. Attach additional
paperwork if more payment lines are needed.
IMPORTANT: Copy of original Request for Payment is to be submitted with the Confirmation of
Services form.
Signature of department representative (does not need signature authority)
Signing this form confirms that the above mentioned Independent Contractor has met the terms of his/her
contract. Payment may now be made and released to this Independent Contractor.
If service(s) was not provided, check the appropriate box that applies; payment to the Independent Contractor
will not be paid where the box has been checked.
Service
Payment
Date of Service
Amount
Signature
Signature Date
not
Number
provided
1.
2.
3.
4.
5.
Submit all Confirmation of Services Performed Forms to Accounts Payable.
Fax: 760-750-3286
Email: icconfirmation@csusm.edu,
hand-deliver: Accounts Payable in Craven 4600
Revised:
0 2/23/10
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Parent category: Business