Administrative Payment Request

GENERAL

INSTRUCTIONS:

1. Review the Detailed Instructions for Admin Payment Form

2. Complete the form and use the button below to display a printer friendly version.

3. Print the "Printer Friendly Version" of the form.

4. Return the completed form, receipts, and supporting documentation to:

University Controller Accounts Payable Department

Foundation Building (FND 280)

6300 State University Drive

Long Beach, CA 90815-4680 USA

Fields with * are required.

*PAYMENT TYPE CHECK WIRE TRANSFER ACH/EFT

Note: If wire transfer is requested by payee, please attach the wire transfer instructions to the completed form.

TODAY'S DATE: *NEED BY DATE (mm/dd/yy):

*AMOUNT $

VENDOR #

*REFERENCE #

PAYABLE TO *Payee Name line 1

Payee Name line 2

*Street

*City *State *Zip Code

*PURPOSE

*Chartfield Information

Amount	Account	Fund	Dept ID	Program	Class	Project
$
$
$

Total GF/Special Fund Amount $

PICK-UP Reason

Last Name First Name Campus Extension

STATEMENT OF REQUESTOR AND APPROPRIATE ADMINISTRATOR'S RESPONSIBILITY

I certify this payment is consistent with business practices for the University and is required for operations.

*Requestor PRINT NAME

Requestor's Signature Date (mm/dd/yy)

*APPROPRIATE ADMINISTRATOR PRINT NAME

Appropriate Administrator Signature Date (mm/dd/yy)

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DETAILED INSTRUCTIONS

Administrative Payments Definition

Administrative payments are defined as payments made on behalf of the University and are required for operations. These payments are not for goods or services and typically will not be supported by an invoice from a vendor. Documentation in support of the payment may be an account/project reconciliation, or request letter. In many instances these payments may be characterized as flow through transactions or administrative adjustments in which the University has collected monies and is in turn making the appropriate disbursement to an individual, corporation, auxiliary, or government agency.

Some examples of administrative payments would include:

Governmental payments
- State Board of Equalization
- Franchise Tax Board
- Internal Revenue Service
Transfers or reallocations to Auxiliaries
Transfers to or from other State Agencies, CSU’s or UC’s
Facilitating the Claims process with the State Controller’s Office
Establishing Change Funds or Petty Cash
University Credit Card or Postage Consolidations:
- Procurement Card
- Business Travel Accounts
- Postage Bank Replacements
Refunds for deposits

To request an administrative payment, submit a completed, signed and approved, “Request for Administrative Payment” form along with supporting documents to the Controller’s Office- Accounts Payable, FND suite 280 – MS 9901. If you need assistance please contact the Controller’s Office Accounts Payable, Ext 5-2512

Indicate method of payment desired, check wire transfer or ACH/EFT - If wire transfer, wire instructions as provided by the payee must be provided to Accounts Payable.
Today’s Date/Need by Date - Complete date sections (Please allow 5 business days for processing once received in Accounts Payable).
Amount of payment - All payments will be in US dollars unless otherwise indicated.
Vendor # - Please indicate the People Soft/Oracle Vendor number. If this payee is new to Oracle, a vendor 204 form may be required. For refunds of amounts collected from the public, no 204 is required. If you need assistance, please contact the Accounts Payable department.
Ref # - Enter the department’s internal reference number
Payee Information - Name, Address, City, State and Zip
Purpose or Reason for Payment - Provide a brief explanation of the need for the payment. Examples: quarterly sales tax payment, transfer to auxiliary for monies held at the state, refund of deposit, payment of management fees
Chartfields – Indicate the PeopleSoft chartfields to which the disbursement is to be charged.
Check Pick-up Information - All checks will be dispatched via U.S. mail unless otherwise indicated in this section. The reason or justification for pick-up must be noted. Examples: Must include tax forms, must send certified mail, must deposit at cashiers.
Name & Signature – Enter the names and signatures of employee requesting the payment and the appropriate approving administrator.