EMPLOYEE LUMP SUM PAYMENT CERTIFICATION
This form is to be competed and returned to Payroll at the completion of the work and will not be
accepted or paid before the end date on the Form 500.
I, _____________________________________________do hereby certify that the following service,
_________________________________________________________________________, was duly
performed/completed on _________________ and that it corresponds with the service contracted for.
I further certify that the amount of $ ________________ is due for such service, and this amount is true,
correct and unpaid.
_________________________________________________________________________________
Employee Signature
UIN
Date
I certify that the above named employee has met all requirements to be paid as indicated on the Form
500.
___________________________________________
Department Supervisor or Chair in charge of the work
______________________________
Date
_____Check here if you will be picking up your check
_____ Check here if you want your check mailed.
_____ Have you attached a copy of a photo id?
_____ Address where you want the check mailed:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Revised March 2012