UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE
FORM NUMBER: FORM 0014
FORM TITLE: Disbursement Request
EFFECTIVE DATE: April 1, 2005
PAGE (S): 2
* Refer to University Policy 05-06-03 for detailed instructions.
* Do not complete shaded areas of form.
* Do not use the Disbursement Request for payments that can be made with a
University P-Card, such as professional dues, registrations, and
* Original supporting documentation must be stapled to the back of the request.
* Paperclip any enclosures to the front of the request.
* Vendors are paid approximately 25 days from the invoice date unless otherwise
* Disbursement Request payments will be mailed directly to the payee approximately
25 days from the invoice date unless the Account Administrator provides a written
request with adequate justification for
an exception to this policy.
* Payments to U.S. residential individuals, businesses, organizations, etc., must have
a social security number or a U.S. Federal Identification number; otherwise, 30%
federal income tax may be withheld from payment.
* If payment is to a Foreign National, see Section VI.
1. Invoice Date – Date of invoice or other supporting documentation, if applicable.
2. Payment Due Date – Date when payment is due. DD-MMM-YY.
SECTION II – PAYEE INFORMATION
3. U.S. Taxpayer Identification No. – Social Security Number, U.S. Federal
Identification Number or U.S. Taxpayer Identification Number.
4. Enclosure – Check enclosure box if attachment is to accompany the check.
5. Payee Name – Individuals and sole proprietors – legal name as it appears on social
security card. Other entities including corporations and partnerships – business
name as shown on required Federal tax documents on
the “name” line.
6. Address Information – Tax documents will be sent to this address.
SECTION III – ACCOUNT INFORMATION
7. Purpose of Payment – Concise description of payment (e.g., consulting services,
8. Distribution by Account Number – Account number (32 digits) and amount charged.
If payments are split among accounts, enter account number and the amount charged
to each account and total to be paid.
SECTION IV – PAYMENT AUTHORIZATION
9. Requested by – Print requestor’s name.
10. Department/Building/Room – Enter requestor’s department, building, and room
11. Extension – Enter requestor’s telephone extension.
12. Email – Enter the email address of the requestor.
13. Fax Number – Enter requestor’s fax number.
14. Requested By (Signature & Date) – Requestor’s signature and date of signature.
15. Approved By (Print account administrator’s name/title) – Print account
administrator’s name and title.
16. Extension – Enter account administrator’s telephone extension.
17. Email– Enter the email address of the account administrator.
18. Fax Number – Enter account administrator’s fax number.
19. Approved By (Administrator’s Signature & Date) – Account administrator’s
signature and date of signature.
SECTION V – PAYEE PROFILE QUESTIONS
20. All questions must be completed.
SECTION VI – PAYMENTS TO FOREIGN NATIONALS
21. Complete only if payee is a Foreign National.