Vendor Payment Form

Vendor Payment Request
Date

MonthDayYear
Date
Invoice Number
Name*

First NameLast Name
Email*
example@example.com
Phone:
Organization/Company Name
Make Check Payable To*
Address to Send Reimbursement Check*

Vendor Information
Vendor Type*
If Other Please Specify
Description of Services
Have you submitted a current W-9 to CACI?

YesNo
Upload W-9*

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Expenses

Select the dropdown(s) below to submit your expenses.

Consultant/Speaker Fee
Speaker Fee

Please refer to your contract with CACI on what expenses are eligible under your contract for payment

Speaker Fee

	Date of Event	Name of Training or Event	Total Training Hours	Total Prep Hours	Enter Total Fee
1
2
3
4
5

Total Speaker Hours
Total Speaker Payment
File Upload

Upload any documentation in support of request
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Mentorship Payment Request - Including Trainings Provided by Mentors
Mentorship Payment
Type of Payment Request

MentoringTraining/Speaker
Date*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Prep Hours*
Click Button Below to Add Date
Date 2*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
2 Click Button Below to Add Date
Date 3*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
3 Click Button Below to Add Date
Date 4*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
4 Click Button Below to Add Date
Date 5*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
5 Click Button Below to Add Date
Date 6*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
6 Click Button Below to Add Date
Date 7*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
7 Click Button Below to Add Date
Date 8*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
8 Click Button Below to Add Date
Date 9*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
9 Click Button Below to Add Date
Date 10*

MonthDayYear
Date
Name of Attendee*
Name of Agency*
Provide a Description of the Service Provided and Topics Discussed*
Mentoring Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments

Training Hours
Prep Hours
Total Mentoring Hours
Total Mentoring Prep Hours
Total Training Hours
Total Training Prep Hours
Rate (ex: $81.25)*
Please enter your agreed upon reimbursement rate.
Total Payment
File Upload

Upload any files in support of your request
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Mental Health Supervision Payment Request
Mental Health Supervision Payment Request
Number of Supervision Sessions Seeking Reimbursement For
Date 1*

MonthDayYear
Date
Number of Attendees*
Provide a Description of the Service Provided and Topics Discussed*
Supervision Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
1 Click Button Below To Add Another Session
Date 2*

MonthDayYear
Date
Number of Attendees*
Provide a Description of the Service Provided and Topics Discussed*
Supervision Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
2 Click Button Below To Add Another Session
Date 3*

MonthDayYear
Date
Number of Attendees*
Provide a Description of the Service Provided and Topics Discussed*
Supervision Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
3 Click Button Below To Add Another Session
Date 4*

MonthDayYear
Date
Number of Attendees*
Provide a Description of the Service Provided and Topics Discussed*
Supervision Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
4 Click Button Below To Add Another Session
Date 5*

MonthDayYear
Date
Number of Attendees*
Provide a Description of the Service Provided and Topics Discussed*
Supervision Hours*
Enter Numeric Values Only in quarter hour increments
Prep Hours*
Enter Numeric Values Only in quarter hour increments
Total Supervision Hours
Total Prep Hours
Rate (ex: $81.25)*
Please enter your agreed upon reimbursement rate.
Total Payment
File Upload

Upload any files in support of your payment request
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Mileage Expense
Mileage Expense

Please refer to your contract with CACI on what expenses are eligible under your contract for payment

Mileage Expenses

	Purpose of Travel	Departure Location	Destination Location	Travel	Total Mileage
Mileage 1
Mileage 2
Mileage 3
Mileage 4
Mileage 5

Total Mileage Reimbursement
In order to receive reimbursement for mileage, you MUST upload a MapQuest document for EACH expense.

NOTE: Your MapQuest document must show your start and end destinations for EACH expense requested.
Upload MapQuest Route(s)*

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Travel Expense (other than mileage)
Travel Expense

Please refer to your contract or agreement with CACI on what expenses are eligible under your contract for payment

Travel Expense

	Date of Travel	Purpose of Travel	Departure Location	Destination Location	Type of Expense	Total Cost
Travel 1
Travel 2
Travel 3
Travel 4
Travel 5

Travel Expense Reimbursement
Upload Receipt(s) *

In order to receive reimbursement, you MUST upload backup documentation (receipts) for EACH expense.
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Registration Fee Reimbursement
Registration Fee Reimbursement

Please refer to your agreement with CACI on what expenses are eligible under your contract for payment
Name of Training
Training Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Training Host
Registration Fee
Enter total requested for reimbursement
Certificate of Attendance*

Upload certificate of attendance
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Proof of Payment*

Upload proof of payment showing registration fee was paid.
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Other Expense Reimbursement
Other Expense

Please refer to your contract with CACI on what expenses are eligible under your contract for payment

Expense Reimbursement Request

	Date of Expense	Item Description	Total
Expense 1
Expense 2
Expense 3
Expense 4
Expense 5

Total Other Expense Reimbursement
Upload Receipt(s)*

In order to receive reimbursement, you MUST upload backup documentation (receipts) for EACH expense.
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Total Payment Request
By signing below, I certify that the above is a true statement of reasonable and necessary expenses incurred in the performance official duties for CACI and has not been submitted to another organization for reimbursement.

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Vendor Payment Request

Vendor Information

Expenses

Speaker Fee

Mentorship Payment

Mental Health Supervision Payment Request

Mileage Expense

Travel Expense

Registration Fee Reimbursement

Other Expense