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.

Has the Cost Center Manager reviewed and approved this payment request?

Check/Payment Information

Total Amount of Check:

Disposition of Check:

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:

Do you have a second account to be charged?

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:

Do you have a third account to be charged?

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):

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

Please verify that you are human:

Sender Name: