Recharge/Service Center (RSC) & Billing Set Up Application and Revisions Request

Recharge/Service Center (RSC) & Billing Set Up Application and Revisions Request
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Initiate a request by choosing the type of request you need below (New or Revised).
Is this a new or revised request?*

NewRevised
How much revenue will be generated annually?

Less than $10,000Greater than or equal to $10,000

the form
Date

MonthDayYear
Date
Service Center Name*
Cost Center Number (if applicable)
Cost Center Number*
Program Number (if applicable)
Requestor*

First NameLast Name
Requestor Email*
example@example.com
Requestor Cost Center Number*
Chair, Director or Dean*

First NameLast Name
Chair, Director or Dean Email*
example@example.com
Section 1
Provide reason for the new/revised service center, and provide description of goods or services to be provided/revised:*
Is this an activity in which you are already involved?*
How does this proposed service relate and benefit the instruction, research and/or public service mission?*
Please provide a narrative that explains how the service meets the following criteria:
- The service is not readily available outside KUMC.
- The service has a research purpose or helps educate students.
- The service does not compete with private enterprise.
Explanatory narrative*
Where will this service be provided (physical location, e.g. building, room)?*
Section 2

Billing/Contract Rates
Internal Billing*

yesno
ISP Number
External Billing*

yesno
Is this a new rate(s) request?*

yesno
Date of Approval*

MonthDayYear
Date
Is a rate(s) currently charged for the service?*

yesno
What is the current rate(s) and how was the amount of the rate(s) determined?*
What rate(s) do you wish to charge and how was the rate calculated?*
Upload the list of rates or contract you would like to charge.*

Browse Files

Cancelof
Upload the rate calculation and the cost justification of the rates you would like to charge.*

Browse Files

Cancelof
Will you be billing for a service or services?*

yesno
Will you be billing for goods?*

yesno
NORMAL OPERATIONS: How will the service or sale of goods affect normal operations?*
Will any FTEs be funded from this service center?*

yesno
FUNDING INFORMATION: (Cost Center number, fund, function and description where funds for this service have previously been deposited - where applicable)*
ALTERNATIVE SOURCE OF FUNDS: (Provide a description, including cost center numbers of other funding sources that will be used to pay for the costs of the service in the event that insufficient income is collected.)
Alternative Source 1
Alternative Source 2
SOURCE OF FUNDS FOR CAPITALIZED START UP COSTS: (Provide a description, including cost center numbers of other funding sources that will be used to pay for initial capitalized start up costs (e.g. capitalized equipment. Reminder – capitalized start-up cost cannot be recovered through the service center.)
Capitalized Start Up Source 1
Capitalized Start Up Source 2
SUBSIDY WHEN RATE CHARGED IS LESS THAN CALCULATED (If the rate to be charged is less than the rate calculated, please give the source and the reason for the subsidy.)
Subsidy*
Reason for Subsidy
List anticipated Non-Salary Expenses and how the expenses support the RSC Account

Chair, Director or Dean code
I have reviewed and approve this submission*

yesno
Reason for non-approval:*
Date submission approved by Department Chair, Director or Dean*

MonthDayYear
Date
Department Chair, Director or Dean signature*

Clear

Control & Reporting code
Review*

Reviewed and approved by Control & Reporting, and request is being advanced to Director of Accounting & Financial Reporting as notification of approval.Review and setup is complete.Application is not needed. Request is dismissed.Reviewed and Request Rejected
Notes
Date reviewed by C&R of initial submission*

MonthDayYear
Date
Notify Requestor

Cost Center/Program Number and In-service Provider info are set upNot readyApplication Rejected
Date notify requestor initiated by C&R

MonthDayYear
Date
Should be Empty:

Recharge/Service Center (RSC) & Billing Set Up Application and Revisions Request

Section 1

Section 2