STIPEND REQUEST (To be completed by Department for each individual stipend being requested)
Name:
Employee ID Number:
Department:
Employee Benefit Type:
Payroll
Bi-weekly 
Monthly 
Description and date(s) of service performed:
Number of Hours Worked:
Date(s) of pay period:
From
To
Supervisor Name
Supervisor ID Number:
Amount Requested: $
P
O
E
T
S
SIGNATURES:
Dean or Director:
Date:
Print Name:
Budget Manager:
Date:
Print Name:
Provost Office:
Date:
Print Name:
INPUT
Date
VERIFIED
DATE
Please send the signed and completed Stipend Request form as an attachment to Debbie Gough at gough@sandiego.edu
or you may print and fax it to extension 2210.