UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE

FORM TITLE: DISBURSEMENT REQUEST
NUMBER:     FORM 0014
PROCEDURE:  05-06-06
DATE:       April 1, 2005


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.