Employee Payment Request Form
(Form may only be used for reimbursement types listed.)
Campus Reference #
10 Digits alpha/numeric or Requisition #
BUSINESS / DESCRIPTION OF PURPOSE (REQUIRED FOR ALL PAYMENTS):
(FOR AP USE ONLY)
REFUND OF FUNDS PAID TO GEORGIA TECH
(Key deposit, BUZZ Card, Parking, Payroll, Bursar Initiated Refunds, STRAP, etc.) VOUCHER #:
REIMBURSEMENT TYPE
REIMBURSEMENT FOR GROUP MEAL EXPENSE ENTERED BY: DATE
(Include Food/Group Meal Summary Documentation Form and original invoice/receipt.) :
PROGRAM ADVANCE/ REIMBURSEMENT - FOR PARTICIPANT RESEARCH
(Provide PI name, budget estimate and research dates and appropriate supporting
documentation.)
PROGRAM ADVANCE (For study abroad participants. Provide project scope, budget estimate, program dates.)
STUDENT GROUP/GT SPORTS CLUB TRAVEL & REIMBURSABLE EXPENSES (Provide list of attendees and original invoices/receipts.)
HOTEL DEPOSIT REIMBURSEMENT (Paid original receipt and a copy of TA required)
EMPLOYEE NAME: EMPLOYEE ID:
Last name, First name EMP ID Look-Up
PAYEE INFO
ADDRESS REQUIRED ONLY FOR NON-EFT PAYMENTS
ADDRESS: Mail Check
CITY, STATE, ZIP: Call For pick-
Up
NOTE: ALL ELIGIBLE PAYMENTS WILL BE SENT VIA THE EFT DIRECT DEPOSIT ACCOUNT ESTABLISHED FOR
PAYROLL
Link to Chart of Accounts
ACCT INFO
Project # Account Code: Amount $
Project # Account Code: Amount $
GT FDN / GTRC Fund Agency or Student Activity Fund TOTAL $ 0.00
For employee reimbursements, employee must sign below. "I certify that purchase was made using personal funds and supports Institute
EMPLOYEE
business. I have not received nor will seek reimbursement from any other source for any portion of the expense claimed."
Employee Signature Date
"I certify that I have reviewed this payment and find it compliant with Georgia Tech procurement policies & procedures. The payment is an
appropriate expense to the fund source(s) identified and I hereby authorize payment."
DEPT APPROVAL
Authorized Approval Signature Date
Printed Name of Approver Title
Supplemental Approval Signature Title
(Required for all payments over $500)
Printed Name of Dept Contact Phone #
Route form to Accounts Payable, Mail Code 0253
404-894-5000 For Assistance:
[email protected] Employee Payment Form 5/2012
