EMPLOYEE LUMP SUM PAYMENT CERTIFICATION This form is to be competed and returned to Payroll at the completion of the work and will not be accepted or paid before the end date on the Form 500. I, _____________________________________________do hereby certify that the following service, _________________________________________________________________________, was duly performed/completed on _________________ and that it corresponds with the service contracted for. I further certify that the amount of $ ________________ is due for such service, and this amount is true, correct and unpaid. _________________________________________________________________________________ Employee Signature UIN Date I certify that the above named employee has met all requirements to be paid as indicated on the Form 500. ___________________________________________ Department Supervisor or Chair in charge of the work ______________________________ Date _____Check here if you will be picking up your check _____ Check here if you want your check mailed. _____ Have you attached a copy of a photo id? _____ Address where you want the check mailed: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Revised March 2012