Allen School External Forms » Allen School Non-UW Employee Payment/Reimbursement Request

Your email address:

Who is this request for?

The request submitter (me)

A different person

Please enter your name and your affiliation to the Allen School/UW:

Please enter the name of the person this request is for and their affiliation to the Allen School/UW:

Contact Number:

PI (Principal Investigator/Faculty Member):

Enter the name of the PI who is funding this expense

Special Requests

If any of these special situations apply to your request, please select appropriate box(es)

This Request is:

Class/Instruction related

Faculty Recruitment related

Student Recruitment related

PI Funding Source(s):

Please provide as much information as possible about how expense(s) in this request will be funded. Can provide funding source name(s), funding source number(s), or both. If you do not know how expense(s) in this request will be funded, write “Unknown”. (Example: “GFXXXXXX Faculty Development” can be “GFXXXXXX”, “FacDev”, “GFXXXXXX Faculty Development”) If multiple PIs are covering expense(s) in this request, please provide as much information as possible about the funding breakdown (e.g., % + PI name + funding source). (Example: “50% Bulzomi FacDev, 50% Yamaoka Startup”)

Business Purpose and Benefit to the Award Statement:

If you do not have a business purpose written, the PI funding this expense should provide one.

Does Payee have an existing Miscellaneous Payment Identification #?

Yes

No

Unsure

(Example: MPE-00012345)

Miscellaneous Payment Identification #

Please use exactly format: MPE-000#####

Payee Legal Name:

(Example: Name on Passport/Visa Documents/Social Security Card)

Additional Comments:

Anything you recall from a previous reimbursement that will help us find you in our system.

Will This Be a Recurring Payment/Reimbursement?

Yes

No

Payee Category:

Payee Contact Number:

We will reach out to your payee to obtain their payment/reimbursement details and residency status.

Payee Mailing Address:

City

State/Province

Zip/Postal

Country

Payee Contact Email:

We will reach out to your payee to obtain their payment/reimbursement details and residency status.

Payment Method:

Request Category (Select All That Apply):

Honorarium Details

Please attach invitation

Honorarium Amount:

Format is to the second decimal place. Ex 123.45

Non-UW Employee Travel Details

Please attach:

Completed claim form (under Non-Employee Travel) – Note: Please read and acknowledge Universal Payee Requirement
Itemized receipt(s)

Services Details

Please attach invoice

Invoicing requirements here. Note: PO number is not required for Miscellaneous Payments

Services Amount:

Format is to the second decimal place. Ex 123.45

Reimbursement Details

Please attach itemized receipt(s)

Reimbursement Amount:

Format is to the second decimal place. Ex 123.45

Other Details

Describe Non-UW Employee Payment/Reimbursement:

Non-UW Employee Payment/Reimbursement Amount:

Format is to the second decimal place. Ex 123.45

Additional Details

To help us assist you more effectively, please provide any additional details about your request and the email addresses of anyone who should be included on this ticket:

Attach Files

Please attach the following documents:

For non-travel payments/reimbursements:
1. Itemized receipt(s) - Highlight alcohol items
2. For Honorarium please attach invitation
3. For services please attach invoice (requirements here)
For travel payment/reimbursements:
1. Completed claim form (under Non-Employee Travel) - Note: Please read and acknowledge Universal Payee Requirement
2. Itemized (travel) receipt(s)

File Upload:

Maximum file size: 52.43MB