Accounting Services Ad Hoc Payment Request

Your Name (Initiator):*

First NameLast Name

Initiator's Title:*

Initiator's Cost Center:*

Initiator's TMCC Email:*

example@tmcc.edu (watch for typos, as this email will be sent a copy of this submission)

Initiator's Phone Number:*

Please enter a valid phone number.Format: 000-000-0000.

Cost Center Manager

Manager's Name:*

First NameLast Name

Manager's Cost Center:*

Manager's Email:*

example@tmcc.edu (watch for typos, as this email will be sent a copy of this submission)

Manager's Phone Number:*

Please enter a valid phone number.Format: 000-000-0000.

YesNo

Check/Payment Information

Total Amount of Check:*

Mail to individual or supplier, as addressed (below)To be picked up by departmentTo be picked up by payeeTo be sent to (list Mail Stop #/Attention to):Other

Reason for Payment:*

Individual or Supplier Information

Issue and mail check to the following supplier unless noted otherwise, above.

Individual or Supplier Name:*

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Account(s) To Be Charged

Unit:*

Cost Center:*

Fund:*

Function:*

Worktag:*

Program, Project, Gift or Grant

Spend Category:*

Description:*

Amount:*

YesNo

Second Account To Be Charged

(2) Unit:*

(2) Cost Center:*

(2) Fund:*

(2) Function:*

(2) Worktag:*

Program, Project, Gift or Grant

(2) Spend Category:*

(2) Description:*

(2) Amount:*

YesNo

Third Account To Be Charged

(3) Unit:*

(3) Cost Center:*

(3) Fund:*

(3) Function:*

(3) Worktag:*

Program, Project, Gift or Grant

(3) Spend Category:*

(3) Description:*

(3) Amount:*

Attachments

Attach Receipts, Sales Slips and/or Invoice(s):

Please verify that you are human:*

Sender Name: