Clear Form
INSTRUCTIONS
Date Enter the current date MM-DD-YY.
Print
Name Enter payee name.
Honorarium Check Request Form
Address Enter payee address.
Social Security Number Enter payee social security number.
To be completed by department:
Check payable to:
Date:
Type of Service rendered Describe the type of service rendered (speaker, proctor, tour
Name
host, guest musician, etc.)
Address
Account Number Enter the twelve-digit account number
X-X-XXXXX-XXXXX. Incomplete or innacurate account
Social Security Number
numbers will necessitate returning the Honorarium Check
Type of Service rendered
Requisition Form for clarification and will cause a delay in
issuing the check.
Payment for
12-digit account number
Amount
X-X-XXXXX-XXXXX
Amount Enter the amount to be paid for each line item. A Travel
Honoraria
Expense Report must be filled out for travel reimbursements
Travel (if any)¹ ²
and attached to the Honorarium Check Requst along with
Other expenses (if any)²
related original receipts.
¹ Travel Expense Report must be filled out and attached
Total
0.00
-
$
² Receipts/Invoices must be attached
Check to be sent to payee?
Yes
Total Enter the total amount to be paid. The check will be
No
written for this amount.
be sent to ___________________________________________________________________________
Check sent to Payee? Indicate whether the check is to be sent to the payee
Signatures:
Phone
named above.
Date
_______________________________________________
_______________
_______________
Purchaser
Purchaser The signature of the purchaser is required here.
_______________________________________________
_______________
_______________
Budget Officer
Return completed form to Accounts Payable
Budget Officer The signature of the budget officer is required here.
Honorarium Check Requisition Forms will not be
processed without budget officer signature.
For Accounts Payable Use:
Approval for payment:
Initials
Date
A/P: _________
________
Date received A/P
Controller: _________
________
Voucher number
Use for
See www.calvin.edu/admin/fsrv/honorpay.htm
Return Completed form to Accounts Payable