"Check Request Template"

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CHECK REQUEST
Date________________
PAYEE
ADDRESS
Is the payee or beneficiary of this payment a U.S. Citizen or Permanent Resident Alien?
Yes 
No 
Don’t Know 
(If Yes, there is no change to current procedures; if No or Don’t Know, provide the payee with a Tax
Compliance Notification Sheet (TCNS) and a W-9*. When the completed form(s) are returned to you, attach
the form to the check request and supporting documents. Forward the entire packet to Accounts Payable.)
Yes 
No 
Gross Up:
Is this compensation for services? Yes 
No 
(If yes, and payee is an employee, please process through payroll.)
Yes 
No 
Is this for reimbursement for expenses for an employee?
(If yes, please use Employee Expense Reimbursement Form)
Fund
Organization
Account
Activity
Amount
Description
Approval by
Date wanted:_____________________________
Total : $____________
Dept. Head:____________________
 Return to Department (Name)_____________________
 Send in U.S. mail
 Hold for Pick-up @ A/P
*See Business Office website for forms
CHECK REQUEST
Date________________
PAYEE
ADDRESS
Is the payee or beneficiary of this payment a U.S. Citizen or Permanent Resident Alien?
Yes 
No 
Don’t Know 
(If Yes, there is no change to current procedures; if No or Don’t Know, provide the payee with a Tax
Compliance Notification Sheet (TCNS) and a W-9*. When the completed form(s) are returned to you, attach
the form to the check request and supporting documents. Forward the entire packet to Accounts Payable.)
Yes 
No 
Gross Up:
Is this compensation for services? Yes 
No 
(If yes, and payee is an employee, please process through payroll.)
Yes 
No 
Is this for reimbursement for expenses for an employee?
(If yes, please use Employee Expense Reimbursement Form)
Fund
Organization
Account
Activity
Amount
Description
Approval by
Date wanted:_____________________________
Total : $____________
Dept. Head:____________________
 Return to Department (Name)_____________________
 Send in U.S. mail
 Hold for Pick-up @ A/P
*See Business Office website for forms