ࡱ> lok jGbjbjo>o> >b T T| 88888LLL8h<L )L L(W(Y(Y(Y(Y(Y(Y($ ,.T}(]8"  ""}(884(!!!"F88W(!"W(!!'$s$6JhF?$C((0 )G$,/"/s$s$/8$""!"""""}(}(""" )""""/""""""""" : FROM:  FORMTEXT College/Division  FORMDROPDOWN   FORMTEXT {Date of Payment Request}IT IS REQUESTED THAT DISBURSEMENT BE MADE TO:  FORMTEXT {Person, Firm or University}  FORMTEXT {Address of Person, Firm, or University}FROM FOUNDATION ACCOUNT #  FORMTEXT       FORMTEXT {Name of Account}PREPARED BY:  FORMTEXT      EMAIL/PHONE:  FORMTEXT       This disbursement of funds is for the following as per the attached documents. (Please include name of the payee, names of recipients of scholarships or fellowships or a description of faculty enhancement program, or explanation and breakdown of any other ways the funds might be used.):  FORMTEXT {Type explanation here.} Check one of the following and provide the information requested:  FORMCHECKBOX  DIRECT PAYMENT Total Amount requested: $ FORMTEXT        FORMCHECKBOX  Reimburse UHS department for expense already incurred.  FORMCHECKBOX  Transfer funds to UHS department for future expenses. Description of expense (attach receipt) or restriction on funds:  FORMTEXT       Department revenue account (outside support):  FORMDROPDOWN  Department cost center:  FORMTEXT        FORMCHECKBOX  GIFT-IN-KIND PAYMENT Total Amount requested: $ FORMTEXT        FORMCHECKBOX  Pay UHS auxiliary or service center for goods/services that directly benefit a UHS department. Auxiliary / Service center name:  FORMTEXT        FORMCHECKBOX  Pay vendor or reimburse UHS employee for goods/services that directly benefit a UHS department. 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8j *h h5OJQJU^JfHq >j *h h5OJQJU^JfHq @6@:@<@P@R@T@^@ٵwuwkL%LjhDh5OJQJU^Jeh fHq r =hDh5OJQJ^Jeh fHq r hIoOJQJ^JUhwdOJQJ^Jh h>*OJQJ^JJjhDh5OJPJQJU^Jeh fHq r FjhDh5OJQJU^Jeh fHq r LjhDh5OJQJU^Jeh fHq r endor/UHS employee address:  FORMTEXT       Invoice number (attach invoice/receipt):  FORMTEXT       Department revenue account: 42909  Gifts in Kind Restricted Department expense account1:  FORMDROPDOWN  Amount: $ FORMTEXT       Department expense account2:  FORMDROPDOWN  Amount: $ FORMTEXT       Department expense account3:  FORMDROPDOWN  Amount: $ FORMTEXT       Chartfield One:  FORMDROPDOWN  APPROVAL: College/Division Certifying Signature Title Date Division Vice Chancellor /President Approval (as required) Title Date _________________________________________________________________________________________________ Foundation Approval Title Date     AM No. 03.E.08 Page  PAGE 4 of  NUMPAGES 1 Payment Request Page  PAGE 2 of  NUMPAGES 2 SUPPORT ORGANIZATIONS AND FOUNDATIONS PAYMENT REQUEST Revised 05.2017 ^@`@b@@@@@@@@@g@LjhDhS5OJQJU^Jeh fHq r =hDhS5OJQJ^Jeh fHq r FjhDhS5OJQJU^Jeh fHq r hwdOJQJ^Jh hAA3OJQJ^Jh hSOJQJ^Jh h>*OJQJ^JFjhDh5OJQJU^Jeh fHq r @@@AAA^A`AAAAAAڶvl_U_K*@jhRi5OJQJU^Jeh fHq r h0MOJQJ^Jh^DOJQJ^Jh h0MOJQJ^Jh"OOJQJ^J=h ha5OJQJ^Jeh fHq r hIoOJQJ^JhwdOJQJ^Jh hSOJQJ^JFjhDhS5OJQJU^Jeh fHq r JjhDhS5OJPJQJU^Jeh fHq r AAAAAAAAAAA㿞xnxJ+=hDh^D5OJQJ^Jeh fHq r FjhDh^D5OJQJU^Jeh fHq r h^DOJQJ^Jh h^DOJQJ^Jh^D5OJQJ^Jhyh0M5OJQJ^J@jhRi5OJQJU^Jeh fHq r FjwhRi5OJQJU^Jeh fHq r 7hRi5OJQJ^Jeh fHq r AAAAAA2B4B6B:B*OJQJ^JhdkOJQJ^J h&$h&$CJOJQJ^JaJh&$OJQJ^Jh hOJQJ^JhXOJQJ^Jhah>*OJQJ^Jh hOJQJ^Jh@OJQJ^Jh[.,OJQJ^JhEOJQJ^Jh haOJQJ^Jh0|OJQJ^JhaOJQJ^Jh~ha5OJQJ^J *h e OJQJ^JDDD~EEEEEEEEEEEEEEEEEEEEEEEF^F$ $a$gdam$gd=DFEHEJE^EhE~EEEEEEEEEEEEEEEEF$F&F2F4F6F8F@FBFVFXF˾wwewww#hpv5CJOJQJhmHnHu!jhpv5CJOJQJUhhpv5CJOJQJhhpv5CJOJQJhpvhq_[jhq_[UhahB >*OJQJ^Jh hB OJQJ^JhaOJQJ^JhB OJQJ^Jh@OJQJ^JhZ>*OJQJ^Jha>*OJQJ^J XFZF\F^FfFhFFFFFFFFFFFFFF>G@GBGTGVG^G`GdGfGhGjGͽ͵͵͵͵͉͘}ykhahB >*OJQJ^Jhq_[h qhshRihLH hG@GBGbGdGfGhGjGgdam$$a$gd&$ $a$< 00&P1:piX/ =!"#$% DText15College/Division@Df Dropdown1 Choose Campus UH - Main UH - SystemUH - Clear Lake UH - VictoriaUH - Sugar Land UH - DowntownDText1{Date of Payment Request}$$If!vh#v(:V l t0(6,5(ytH*D{Person, Firm or University}D({Address of Person, Firm, or University}$$If!vh#vv:V l| t0(6,5vytetDText4DText5{Name of Account}$$If!vh#vv:V lQ t0(6,5vpyt`tDText4jD$$If!vh#vv:V l t0(6,5v/ yt;7D{Type explanation here.}tDCheck1vDText10tDCheck1tDCheck1jDDf  42920 - Funds from FERV42921 - Funds from HAO42922 - Funds from HAF!42923 - Funds from COB Foundation!42924 - Funds from Law Foundation 42925 - Funds from UH Foundation 44400 - Used by ACB, Memberships%44443 - Used by ACB, Special Projects44444 - Used by ACB, ServicestDText8tDCheck1vDText10tDCheck1tDText8tDCheck1tDText8tDText8tDText8DfChoose ExpenseChoose Expense 52121 - Professional Services52408 - Program Support53400 - Official Functions"53401 - Official Functions-Alcohol53920 - Office 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