Direct Payment Request

General Instructions

Review the Detailed Instructions for Direct Payment Form
Complete the form and use the button below to display a printer friendly version.
Print the "Printer Friendly Version" of the form.
Return the completed form, receipts, and supporting documentation to:
University Controller's Office - Accounts Payable, Foundation Building Suite 280 MS 9901, 6300 State University Drive, Long Beach, CA 90815-4680

Fields with * are required.

*DATE:

*REQUESTING DEPARTMENT

DEPARTMENT REFERENCE #

INVOICE #

*INVOICE DATE:

*INVOICE AMOUNT $

*PAYEE TYPE EMPLOYEE STUDENT OTHER

VENDOR DATA RECORD 204 FORM ATTACHED 204 FORM ON FILE

ORACLE VENDOR NUMBER

*Employee/Student ID#

PAYABLE TO *Payee Name line 1

Payee Name line 2

*Street

*City *State *Zip Code

Chartfield Information

Amount	Account	Fund	Dept ID	Program	Class	Project	Billable to Third Party	Billing Number
$
$
$
$
$

TOTAL CHARTFIELD $

COMMENTS

PICK-UP REQUIRED (OPTIONAL) Last Name First Name Campus Extension
Reason

STATEMENT OF PAYEE'S RESPONSIBILITY

I certify that this expenditure is necessary for the department's operations and the University's mission. If requesting an employee or student reimbursement, their signature is required.

*REQUESTOR/EMPLOYEE/STUDENT PRINT NAME

Requestor/Employee/Student Signature Date

Statement of Appropriate Administrator / Approver's Responsibility

I certify that the funds are available for this expenditure and that this expenditure is reasonable and necessary for the department's operations and the University's mission

APPROPRIATE ADMINISTRATOR/APPROVER PRINT NAME

Appropriate Administrator/Approver Signature Date

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DETAILED INSTRUCTIONS

Date: Input the date the Direct Payment form was completed
Requesting Department: Input the name of the department requesting payment
Department Reference Number (optional): Enter the department’s internal reference number
Invoice #: If known, enter the invoice number
Invoice Date: Enter the date of the invoice
Invoice Amount: Enter the total amount due to the payee (including tax, shipping, etc.)
Payee Type (select one): Indicate whether the payee is an employee, student, or other type of vendor
Vendor Data Record: Indicate whether you have attached a Vendor 204 or if one is on file with Accounts Payable (Check one box only)
Oracle Vendor ID#: Input the PeopleSoft/Oracle vendor ID number if known. If the number is not known, it will be provided by Accounts Payable
EMPLID/Student ID: If the Payee is a student or employee the employee/student ID number must be provided
Payable to: Enter the legal name of the vendor. This must match the name provided on the Vendor 204 form
Remittance Addres: Input the vendor’s mailing address
Chartfield Information: Input the amount due and the chartfield information. You may breadown the amount being paid by different chartfields. Use multiple lines if there is a separate amount, fund, Dept ID, program, class, or project number
Billable to 3rd party: If any amounts are being billed to an auxiliary or other 3rd party, this section must be completed, including the billing number (ex. Grant billing number 07-xxxxx)
Comments: Enter any comments that may assist Accounts Payable in processing your request. For example: describe the event or nature of the payment. When issuing an employee or student reimbursement, please enter “Reimbursement”.
Pick up Required (optional): For internal control reasons and as a standard procedure all checks will be sent out via regular mail. If a valid reason can be demonstrated, such as the check must be included with a confidential mailing or must be presented in person to a government agency, pick- up may be arranged at the Controller’s Office. Use the space provided to indicate the name of the person authorized to pick-up the check, his/her telephone extension, and the reason for the pick-up.
Signature Approval: Obtain appropriate signature approval from the department. If the Direct Payment Request is for an employee/student, their signature is required.