ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
CHECK ONE:
INVOICE#s
DATE:
2
 Payment of Invoice
3
Advance
4
 Reimbursement
Grant Expenditure?
YES NO X
5
 XPayment for Services
(circle if applicable)
6
(See box below)
If Yes, please attach grant summary sheet
7
8
PAYMENT FOR SERVICES ONLY, please check one of the following:
9
10
I am currently employed by the Vermont State Colleges. Payments will be made through
11
Payroll. This includes student employees as well.
12
I am not currently employed by the VSC. A completed W-9 is attached or on file with
13
Accounts Payable. I understand the VSC is required to file a 1099 with the federal
14
government on all non-corporate payments in excess of $600 on a calendar year basis.
15
16
Colleague/Vendor#:
17
Payable to:CHECK ONE:
18
Address:
Pick up in Business Office
19
 X
Mail Check to address provided
20
EFT Direct Deposit
21
Provide detailed DESCRIPTION of the BUSINESS purpose for the goods, services, or reimbursements being purchased or reimbursed in this section of the
22
Request for Payment Form (supporting documentation must be attached):
23
24
Cooperating Teacher stipend - Practicum
25
26
27
Please Charge G/L Account(s):
Amount of Request:
28
29
GASB ACTIVITYPROGRAMOBJECTLOCATIONPROJECT IDAMOUNT
30
(# of Digits Required)
31
$200.00
32
33
34
35
TOTAL$200.00
36
37
REQUESTER: SIGNATURE:
ADVANCE/CONTRACT
38
Date:SIGNATURE:Xdate:
39
Extension #
40
are for Business purposes, and in the case of an advance,
41
I will return all documentation within ten days of the advance.
42
PERFORMER/PRESENTER agrees to the contract
43
APPROVALS:
44
45
Dept Chair/Budget Mgr/Dir. signature:
Date:
46
(all requests)
47
Divisional Dean signature:
Date:
48
(amounts between $2,000 and $5,000)
49
Dean of Administration signature:
Date:
50
(amounts exceeding $5,000)
51
BUSINESS OFFICE USE ONLY:
52
Please provide any special instructions or additional information below:
53
Voucher #Paid by ACH
54
DatePO#
55
ApprovalOther
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100