Vendor Payment Form

Vendor Payment Request
Tag
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Invoice Number
Name

First NameLast Name
Email
example@example.com
Phone:
Organization/Company Name
CACI's method of payment is ACH transfer. Do you consent to ACH transfer of your payment?
Does CACI already have your bank information on file? Note: if payment is being made to a CAC, bank information is on file.
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?
Upload W-9

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Expenses

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

Consultant and/or Speaker Fee

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

Speaker or Consultant Fee

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

Total Speaker/Consultant Hours
Total Speaker/Consultant Payment
File Upload

Upload any documentation in support of request
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Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hours
Activities:
Provide a Description of the Service Provided and Topics Discussed
Click Button Below to Add Date
Total Hours
Rate
Total Payment
File Upload

Upload Training Certificate or other backup as needed
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Mentorship Payment
Type of Payment Request
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
Number of Supervision Sessions Seeking Reimbursement For
Date 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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

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

Mileage Expenses

Rows	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

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

Travel Expense

Rows	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

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 including Invoices

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

Expense Reimbursement Request

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

Total Other Expense Reimbursement
Upload Receipt(s) or Invoice

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.
Should be Empty:

Vendor Payment Request

Vendor Information

Expenses

Consultant and/or Speaker Fee

Mentorship Payment

Mental Health Supervision Payment Request

Mileage Expense

Travel Expense

Registration Fee Reimbursement

Other Expense including Invoices