CI Payment Request Form
Requester Name
*
First Name
Last Name
Requester Email
*
example@example.com
Requester Phone Number
*
-
Area Code
Phone Number
Payee Name
*
Payee Mailing Address (mailed checks will be issued to this address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payee Phone Number
*
-
Area Code
Phone Number
Payee Email
*
example@example.com
Social Security # / Fed ID #
Not applicable if request is for reimbursement
Upload Payee W9 (for services. Payment will not be issued until this is received.)
Browse Files
Cancel
of
Payment Due Date
*
-
Month
-
Day
Year
Date
Payment Method
*
Mailed Check (check will be mailed to "payment address" as indicated above)
PayPal (please indicate email or phone number to use for payment if different from above)
Zelle (please indicate email or phone number to use for payment if different from above)
Email or Phone Number for Zelle/Paypal Payment
Payment Amount
*
Purpose of Payment
*
Budget Category
Attachment
*
Browse Files
**Supporting documents such as an invoice, proposal, estimate, receipt, or credit card authorization form MUST BE ATTACHED for payment request to be processed**
Cancel
of
Comments / Special Instructions
Signature
*
Submit
Should be Empty: