Requested By:

Name of Organization

Your Email Address

Payee Name

Who is the Payee

Is this payment to or on behalf of a U.S. citizen or Permanent Resident?

Payee Address

City/State/Zip

If you are a student, we have stopped collecting Social Security Numbers via online methods. In order to be reimbursed, write your SSN on the back of the receipt that will be turned in to your advisor. Your SSN is required to be reimbursed.

If a vendor, include the Payee Tax ID Number.

Description of Spending

If your event involved food, how many people were in attendance?

Amount to be Reimbursed (do not include tax)

Account Number

Organization to be Charged

Check Distribution Instructions

If Calling for Pick-up, what is Payee Phone Number?

Submit to OACS: