UAS Disbursement Form

UAS Disbursement Form

For UAS Mission, Agency, Program Funds and Residential Life accounts
Today's Date*

MonthDayYear
Date
Payee Information
1. Payee Name*

First NameLast Name
For individuals or sole proprietors, enter the name in the first Payee Name block. Corporations, partnerships and tax-exempt organizations should enter the name of the entity.
Payee Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Payee Phone Number*
Please enter a valid phone number.
3. Payee Email*
example@example.com
Is this a personal reimbursement to the payee for goods and services for an event?

YesNo
4. Payee Certification for personal reimbursements for expenses. This reimbursement is just, true and correct.

Clear
(For personal reimbursements to the Project Director, please have the disbursement countersigned in Section 6 by a secondary officer.)
Date

MonthDayYear
Date
Is the Project Director receiving a personal reimbursement?*

YesNo
Secondary Officer Counter Signature

Clear
Date

MonthDayYear
Date
5. Account Information
Account Name
Account Name*
Account Number*
For Program Funds, account number is provided on award letter.
Project Director/Contact Person*
Campus Address*
Phone Number*
Please enter a valid phone number.
6. Certification: This disbursement is just, true and correct. *

Clear
Signature of Project Director
Date*

MonthDayYear
Date
Name

First NameLast Name
Disbursement Details

Itemized list of invoices, receipts and services to be paid
Description of Goods/Services 1*
Amount of Goods/Services 1*
Description of Goods/Services 2
Amount of Goods/Services 2
Description of Goods/Services 3
Amount of Goods/Services 3
Description of Goods/Services 4
Amount of Goods/Services 4
Description of Goods/Services 5
Amount of Goods/Services 5
Description of Goods/Services 6
Amount of Goods/Services 6
Total for Goods/Services*
Total for Materials and Services
Attach all invoices and receipts for your disbursement. For Program Funds disbursements, include a brochure, flyer or program from the event. If you have more than six invoices or receipts, please also attach a document with a full list of descriptions of goods/services and their amounts.*

Cancelof
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Should be Empty:

UAS Disbursement Form

Payee Information

5. Account Information

Disbursement Details