CALIFORNIA STATE UNIVERSITY, MONTEREY BAY
ACADEMIC AFFAIRS PAYMENT REQUEST FORM (DIRECT PAYMENT)
THIS FORM IS NOT TO BE USED FOR PAYMENT OF SERVICES TO EMPLOYEES OR STUDENT EMPLOYEES.
SUCH PAYMENTS MUST BE SUBMITTED TO PAYROLL.
DEPT. UNIQUE DOCUMENT NUMBER IF NO INVOICE # :
(Do not duplicate number; used for tracking purposes)
Date :
UNIT
Requesting Department Name:
ACCOUNT
FUND
DEPTID
CLASS
PROGRAM/PROJ
AMOUNT
$
$
$
Total
$
Service Provided (circle one): NO or YES (If YES, see CONTRACTS section below)
Payee Information (Only One Vendor/Payee And One Invoice Per Payment Request)
Payee Name:
Address:
City, State Zip:
,
-
Briefly – describe the nature of the payment:
Justification is required - state the business purpose or benefit:
CONTRACTS (Do not use this form if payment is against a Purchase Order)
Requesting Dept must answer the following questions if this is payment for services provided:
Is there an approved contract with this vendor? NO or YES; If YES, how much is this vendor contracted to be paid $_______________
Has prior payment been made to this vendor under this contract? NO or YES; If YES, how much has been paid $__________________
Will this be the final payment to this vendor under this contract? NO or YES; Internal Use Only: BSS Approval (initial)___________
INSTRUCTIONS
Follow these instructions for completing this form.
1.
2.
3.
4.
5.
6.
Failure to follow may cause the ‘Payment Request’ to be rejected by Accounts Payable.
Do not use this form for departmental chargebacks. Process a ‘Revenue Transfer’ (RT) or an ‘Expense Transfer’ (ET)
depending on the type of chargeback. All University billings, RT and ET are processed through the Accounting Dept.
Do not use this form for employee personal reimbursements. Use ‘Personal Reimbursement and Petty Cash Form’.
An original receipt, invoice, order form, renewal notice or other appropriate document(s) must be attached to this form.
This payment request must be approved by the person with fiscal authority. Their original signature is required to be on
this form.
SPECIAL HANDLING INSTRUCTIONS
Mail Documents with Check: (Supply one additional copy of only the document(s) that you are requesting to be mailed out with the check)
Send Email for Pickup
Dept. Contact Name
Extension No.
Other
If this is a new vendor, a completed Vendor Data Record (VDR or STD.204) must be completed and attached to this form.
The Approving Authority certifies that these expenses are for University purposes and comply with any and all restrictions on the
intended use of these funds.
Prepared By
Extension #
Dean/Designee Signature
Print Name
Approving Authority Signature
Print Name
Provost/Designee Signature
Print Name
For AA use only, revised 1/20/2012