*HONORARIUM RECIPIENT NAME*
*HONORARIUM RECIPIENT ADDRESS*
Thank you, *RECIPIENT NAME*, for your participation in *EVENT*, on *DATE*. To show our appreciation, we would like
to provide you with an honorarium in the amount of
(Amount-required)
(Currency-required).
Unless otherwise required by law or treaty, no employment or income taxes will be withheld. We kindly ask you to
complete the questions below to determine if more information is needed to process your honorarium.
1. Are you a non-resident alien of the United States? Yes 
No 
2. Are you a current Carnegie Mellon employee?
Yes  No 
(If the answer to question # 2 is “Yes” please skip questions 3, 4, 5 and 6.)
3. Please provide the name and address of your employer:
4. Is your employer a foreign government or is your employer owned or controlled
by a foreign government? For purposes of this question “foreign government”
is any government institution outside of the United States.
Yes 
No 
5. Are you or any family member an official of a foreign government?
Yes 
No 
6. Do you anticipate that it will be necessary to interact with any foreign officials
on behalf of Carnegie Mellon?
Yes 
No 
If the information contained herein is accurate and satisfactory to you, please provide your signature below and return a
copy of this letter to *CMU BUYER NAME* at *ADDR/EMAIL/FAX*.
I, *RECIPIENT NAME*, hereby certify that this Honorarium is fully understood and is entirely satisfactory. In addition, I
acknowledge that I have received and reviewed the university’s FCPA guidance available at
http://www.cmu.edu/ogc/fcpa/fcpaguide.html.
Honorarium Recipient Signature
Date
DIRECT DEPOSIT (optional)
 I would like my payment to be direct-deposited to the following account:
Bank Name:
Routing #:
Account #:
(Must be exactly 9 digits)
UCO Use Only:
FCPA Approved
Payment Approved


Matthew D’Emilio, Director, University Contracts Office
Carnegie Mellon Use Only:
Please indicate the ledger for this honorarium:  US
 QAR
 AUS
Honorarium Purchase Order Number: ______________________________________________
(Rev. 8.19.2015)