Central connecticut state university disbursement form

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Central Connecticut State University Disbursement Form

Disbursement Type

Check One:

Payment for PSA #_______________ Refund/Reimbursement

Final Payment?

Yes

No

Payment for Services/Honorarium less than $3,000

Membership/Subscription

Stipend Payment

Other:

Payee Information Name:

FEIN # or Banner ID

(REQUIRED)

Address:

(Payee's Home Address, not department address at CCSU)

Is the Payee a current state employee? Yes ______

No _____

Disbursement Information -Please provide detailed information

Please note: If using the Disbursement Form only to pay a PSA, I understand that I am responsible for ensuring compliance with State and Federal laws, University policies, and that this payment is not for temporary office or other bargaining unit work. I have paid particular attention to the appropriate use of independent contractors. I also understand that audit questions will be referred to me for response. I certify that the services on the above referenced PSA have been rendered and I authorize payment in the amount specified below. (Specific Services for PSA's must be listed below when a PSA Form (CO-802A or CCSU-802A) was not submitted). If I am a project Director and I am picking up a guest speaker or entertainer's check prior to the performance, I certify that I will not allow the check to be released until the services have been satisfactorily provided to CCSU. In the event this does not occur, I agree to return the check to the Business Office the next business day.

REQUIRED: If this disbursement is for any type of service performed, including guest lecturer, entertainer, honoraria please indicate the date(s) the service was performed: _______________________________________

Requestor's/Project Director's Signature:

Funding Information

Date:

Banner Index Banner Account

Grant Funding Approval All use of grant funds MUST be approved by the Grant's Office:

Revised 09/26/12

Amount $ $ $

Budget Authority Signature

Date

Date:

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