RSS Payment Request

RSS Payment Request

Payment Information
Is payment to or on behalf of a US Citizen or Permanent Resident?*

YesNo
Purchase Due Date / Date Service Needed:*
Location of Purchase / Service:*
Cost of Purchase/Service:*
Brief description of the purchase or service provided:*
Payment to:*
Requested Method of Payment*
Name

First NameMiddle NameLast Name
Name*
Please provide the receipient's full name.
Please list the vendor that is receiving the payment*
If you are requesting a check, please provide the organization's name or name of the person that will receive the check.
TIN (e.g. SSN, ITIN, EIN)*
Please provide the last four digits of the TIN. US citizens will have a Social Security Number (SSN). Non-citizens and other non-residents should provide an Individual Taxpayer Identification Number (ITIN). Businesses should supply a Employer Identification Number (EIN).
Vendor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was this a purchase request on a Purchase Order?*

YesNo
Purchase Order Number:*

RSS Payment Request

Acknowledgement
By signing below, you are attesting that all information is accurate and complete.
Signature of Officer completing form*
Second Officer's Name*

First NameLast Name
Second Officer's Title*

PresidentVice PresidentTreasurerSafety OfficerSecretary
Second Officer's Email
example@example.com
Signature of Officer completing form*
THIS SECTION IS FOR OFFICE USE ONLY.
ACCOUNT INFORMATION
APPROVAL
Should be Empty:

THIS SECTION IS FOR OFFICE USE ONLY.