PAYMENT REQUEST FORM

Make Payment To: ______________________________________________ ID #: _____________________

(Use Full name: Last, First, Middle) (UVA student ID, or Faculty/Staff Employee ID, or Non-UVA last 4 of Soc #)

Today’s Date: ____________________ Date of Event: __________________________

SUBMITTED BY: _______________________________________________________

Purpose and Location of Event: _______________________________________________________

TOTAL Amount*: _______________ Program/Task: _______________

*If more than one program, please specify amounts below:
Category: _______________________
Amount _________ PTAO_________________________ (expense type)
Amount _________ PTAO _________________________ Detail: _________________________
Amount _________ PTAO _________________________

Please check one: Breakfast Lunch Dinner Other ___________________________

Total Number of Students/Faculty Attending: _______________

NAMES OF THOSE ATTENDING (IF MORE THAN SIX (6), LIST ONLY OUTSIDE VISITORS BY NAME.
LIST OTHERS BY CATEGORY AND NUMBER (i.e., 15 Students, faculty, & staff).
_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

If request for reimbursement is over 30 days, please list reason why:

________________________________________________________________________________________

ATTACH ORIGINAL RECEIPTS BELOW (tape receipts to the back or continue on a full size paper and attach)

PROGRAM APPROVAL SIGNATURE __________________________________________

BIMS wedge\Forms\Pmts & Orders\Payment Request Form updated 12-2011.doc