REQUEST FOR PAYMENT TO RESEARCH STUDY PARTICIPANTS
Date of Request:
PI Name:
Study Account #:
Subledger #:
Visit #:
Payment Amount: $
Study IRB #:
Name of Study Participant:
Address of Study Participant:
City, State, ZIP:
Important Payment and Tax Information
The U.S. Internal Revenue Service (IRS) considers payments received for participation in research as income. UT
Southwestern Medical Center is required to report payments of $600 or more in a calendar year to the IRS.
However, it is your responsibility to report all income, regardless of the amount, to the IRS on your annual federal
tax return.
UT Southwestern, as a State agency, is not allowed to make any payments to you for your participation in this
research if the Texas State Comptroller has issued a “hold” on all State payments to you. Such a “hold” could result
from your failure to make child support payments or pay student loans, etc. If this occurs, UT Southwestern will be
allowed to pay you for your taking part in this research after 1) you have made the outstanding payments and 2) the
State Comptroller has issued a release of the “hold.”
Payment Information – UT Southwestern Employees
If you are an employee of UT Southwestern, payment will be added to your regular paycheck and federal tax will be
deducted. This form should be emailed to PayrollUTSW@utsouthwestern.edu on or before the next scheduled
payroll cutoff date in order to be paid as promptly as possible.
If you are you an employee of UT Southwestern, please provide Person #:
Social Security Number Disclosure Information – All Subjects
Disclosure of your Social Security Number (SSN) is required in order for UT Southwestern Medical Center to report
miscellaneous income, as mandated by Federal law. Further disclosure of your SSN is governed by the Public
Information Act (Chapter 552 of the Texas Government Code) and other applicable law.
If you do not disclose your SSN, you can still be paid for your participation in the research; however, payments will
be reduced by the required Federal Income Tax non-employee withholding rate, currently 28% (subject to change).
Please provide your Social Security Number for the purpose of receiving payment for your participation in this
research study: SSN:
Note: failure to provide SSN will reduce subject payment after tax withholding to: $
Signature of Research Participant:
____________________________________ Date:
Name of Research Participant:
____________________________________
Coordinator/ Designated
Representative Signature:
____________________________________ Date:
Coordinator/ Designated
Representative Printed Name:
____________________________________
Effective October 1, 2007
Revised July, 2015