UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE 

FORM NUMBER:      FORM 0014

FORM TITLE:            Disbursement Request

PROCEDURE:           05-06-06

EFFECTIVE DATE:    April 1, 2005

PAGE (S):                    2

 

General Instructions
*    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 Subscriptions.
*    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

      indicated.
*    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.

SECTION I

1.   Invoice Date – Date of invoice or other supporting documentation, if applicable.

      DD-MMM-YY.

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,

      speaker’s fees).

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

      number.

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.