REQUEST TO CREATE A PURCHASE ORDER (Used for non-food items) A detailed cost estimate of product or services must accompany this fully completed form. Item to be purchased: (including quantity) Vendor: '' '/ ', ' ' ~ Address: Total cost of item: Date needed: Account Name/number to be charged: Name of requestor; Requestor contact in/o: (email I phone#). ~pur ema ~.(GJ; vpu/. ecl.v Signature of Submitter: Attachment A
HOSPITALITY FORM (Used for food items) --,--Request to create a purchase order v Individual Reimbursement Please check one ATTACH RECEIPTS and ATTENDEES LIST TO THIS FORM: 1. Business/Person to be paid or reimbursed: ~ M( ;.nam 1:. Please pr' t (Campus) Address: Date Submitted:.,..<. ±octij~~ d.afe.. Account number/name:: ~~c...:s=..,;,!b~...:.s.-.:b-::...'_ _.,:...;.. ~-.:.:.:...:.::.;.:.:.:...:.::.; Student Group: k:- S.S S &-.... < 2. 3. 4. 5. 6. Amount of reimbursement requested:. ) 1f> d- 5, 0 0 ---~~------------------------ (original receipts MUST accompany form for reimbursement) Date and Place of Function: d~ b)jd-. : < 13.~ 30 l Cf Natureoffunction{giJ!detaii): J(SBSb ~eeuf(,;e_ m~ef-ifl5- snatks Purpose/B~~E!fit to the Universi~y: fl ~~~ { rt 5. mee +-; t1 -l1r iu -Itt re fl/f n +.s Number of persons attending: (A list otattehdees is also required) '..,.. ' # University Emp.loyeE!s ;,. # Students_<.;;.;.; ~ ~ :::...~... ~.;._...L) 1~' Sut-----. cr~mn~c=-l~~.g:.!::::~::: # Non.Unive~'sity. '..... ------------------------------- <Affili~fiC:>n olnon employee attending:-------------------------- Signature of Submitter:... t)ou ( S I0M-kt r e ~--------------- Signature of Fiscal Officer or Designee {To be signed by Business Office): ------------------------------------- Date:--------- Attachment B
HOSPITALITY FORM (Used for food items) _/_Request to create a purchase order Individual Reimbursement --- Please check one ATTACH RECEIPTS and ATTENDEES LIST TO THIS FORM: "c 1. Business/Person to be paid or reimbursed: ::.C;;;...!.;;;~a~rf!...,;w~e~).;::;..;lf~'s:::..::.: Please print (Campus) Address: 2. Date Submitted: '" : :?J/.}/i~ Account number/narn~: /(5:(5 S (;:: >. ~-~~~~~~~.. ~.~,~-------- Student Group;..: :::: 5 f:f:{l((1 Amount of reimbursement reque~ed:. ::: : ).~3 0 D (original receipts MUST accompany form for reimbur~ement). 3. Date and Place of Function: 3 ~1!J-B. ' I u'fvj-:- c e#(ct ( C.,Curfja rj 4. Natureoffunction(givedetail): Jun('h... f]~~: ftz24 for 4udeA+.s;. 5. Purpose/Beraefit to the UnivE!rsity: 't f\~oqut't" ls$ f3 sttem..jt0 all S~d fll ts 6. Number of P~tsons attending: (A list o(atterldees is also required) ~ ' ' ~ - ', ' '< 0 ' ' ' '"' ' ' ' ' # Unive~~ity Empibyees ~-~-------------------------- #students pea. 4-o a tl 5+uden+s #NonJJniversity ------------------------------. Afffii~ti;on of.non-~mployee attending: -------------------- SignatureofSubmitt,r:.. ~our 3i~Acc4tre... Date: 3/2-)tJ- Signature of Fiscal Officer or Designee {To be signed by Business Office): ------------------Date: Attachment B
INDIVIDUAL REIMBURSEMENT REQUEST (Used for non-food items) You must include an itemized 'paid' original receipt with this completed form. Name: ~otjr Please print Dame Address: Contact Info: (email I phone#) Item(s) purchased: Amount to be reimbursed: Account to be char~eil: )t5(3s{y. Name ofstlldent org: 0SCYY1 Signature of Submitter: Attachment C
W-9 Form Modified US Person or Resident Alien only, Non-Resident Aliens must complete Form W-8BEN Information reauired to satisfy Form 1099 reporting Under the United States Internal Revenue Code, Indiana University is required to obtain Taxpayer Identification Numbers (TIN) when making reportable payments to individuals or corporations. If this information is not provided, certain payments may be subject to a backup withholding rate of twenty-eight percent (28 %). Also, if you fail to furnish a correct TIN, the IRS can access a penalty of $50 unless failure to comply is due to reasonable cause and not willful neglect. Instructions: Complete all parts and return this form to the requesting lu department. This completed form is required to be filed with the University before payment can be processed. For more information and detailed instructions, see http://www.irs.gov/instructions/iw9/ar02.html. Part I -Name, Address and Tax Status...-)- Legal Name: Your t1am e. (As reporte6 for federal in(ome tax purposes [must mat(h number listed below]) (IfTax Type is Social Security Number, the Legal Name MUST be the name of the Individual, NOT a Company Name) Business or Trade Name: ;;:;--::-:---:---:----:~----:-:-:-:---:-:-:----:~~-~~----:--,.--,...----, (Should only be used if you are "doing business as" (dba) a different name than the Legal Name.).::;y Address: --jf-!>'o.!l-v.j...(----loo<:a"""d~d:.:...:~~e...::s:...s_-+;------------------- / ~City:---------'\/'=---- State: ZIP: Telephone Number:----------- Fax Number:---------------- Please jndicate <X> ownership status; Corporation (for profit) (EIN) in on-profit (EIN) Estate/Trust (EIN} LLC, LLP or Partnership (EIN) -income tax return filed under business name Government (U.S., State, Local) (EIN) ;::::,; IndividuaVSole Proprietor or Single Member LLC when income tax return filed under ~ ; tndividual's name-list INDIVIDUAL'S NAME AS LEGAL NAME (SSNIEIN) In addition to the above, please check one of the below if you perform either Health Care or Legal Services: 0 Health Care Services 0 Legal Services Please ur oses and matchin Le al Name above: Social Security Number --OR-- Employer Tax ID Number Part II- Exemption If you are exempt from Backup Withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter your correct name and TIN in Part I and write "Exempt" on line provided here ; sign, date and return to requester (individuals and sole proprietors are not exempt). Part III -Certification Instructions: Cross out item two below if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return. Under penalties of perjury, I certify that: ( l) the number shown of this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me}, and (2) I am not subject to backup withholding because (a} I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and {3) I am a U.S. Person (including a U.S. resident alien). ~~------------~~------~~---------------------- Signature Date Title Purch-Rev 042310 Attachment D
INDIANA UNIVERSITY Vendor Authorization Agreement for Direct Deposit (ACH Credits) of Accounts Payable Disbursements ~ """ u<e wi!_h Disbursement Vouchers. For example: Invoice payments an purchase orders) horization I D Update Existing Authorization D Cancel Authorization D Vendor Name ~our narne Federal Tax 10 Number(s): Bank Account Name (if different than vendor name} Vendor Email Contact Address Contact Name Phone Number c Vendor Address City State Zip youf addres.s Financial Institution Name JJanJt. ftam-e Contact phone number at financial institution City State Zip "J)a_n /( address '""' -:::::::- / Routing Numb:_) (!ank Account Number_:.} Type of Accou~ Checking D Savings D --::::::. / Both parties agree that the addendum information will be provided to the customer In the form of a CCD+ addendum record and, if desired, In the form of an email notification for each invoice paid. ~ Would you like an email remittance notification? YesORemittance Email Address: NoD 1 certify that the information 1 provided Is correct and that 1 am an authorized signer or designate of the account provided for the direct deposit transactions and am entitled to provide this authorization. I (we) further authorize Indiana University to initiate credit entries to the account and financial Institution listed above. 1 (we) further authorize adjusting entries (reversals) to correct errors, if any. This authorization is to remain in effect until indiana University has received written notification from (us) of its termination in such time and manner as to afford Indiana University and the depository financial institution a reasonable opportunity to act on it. IMPORTANT NOTICE ABOUT INTERNATIONAL ACH/DIRECT DEPOSIT Due to new banking regulations, beginning September 18, 2009, funds electronically deposited via Automated Clearing House (ACH) in a U.S. bank and then forwarded to a non-u.s. bank are required to include additional information that is not currently being collected. Until this additional information can be obtained, payments of this nature must be paid by paper check or will be rejected by the ACH network. THIS INCLUDES ACH PAYMENTS PROCESSED BY INDIANA UNIVERSITY FOR EMPLOYEE REIMBURSEMENTS. If you currently forward, or in the future plan to forward, ACH payments to a non-u.s. bank; steps should IMMEDIATELY be taken to inactivate or change your direct deposit information currently on file with Indiana University. YOU NEED NOT TAKE ANY ACTION IF YOU DO NOT AND WILL NOT FORWARD ACH PAYMENTS TO A NON-U.S. BANK. Check here if you plan to forward your ACH to a non-us bank: D (check box) Failure to take action will result in your bank rejecting your international deposit and returning the funds to Indiana University. Indiana University is not responsible for International ACH transactions that are rejected and/or delayed due to missing information. 1 (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law. ~ Signature Date ~Printed Name AP: updated Sept 2010 Title