(SGA-Funded) Student Club
Request for Payment
•
•
•
•
•
You will need all of the information on this form filled out in order to submit this request.
If information is missing, your request will be denied and you will need to resubmit the request.
Plan Ahead! There is a minimum approval and processing time of 14 days.
Approval or rejection of request will be provided within 5 days of submission.
Questions can be directed to Sheryl Ezbiansky at [email protected] or to Jared Ruhl, SGA
Treasurer at [email protected].
• Scan Receipts, Invoices and/or Contracts as a PDF. There are copier/scanners campus-wide to use.
• If using Firefox 19+, an Apple Device, or Google Chrome, open this form in Adobe Reader.
• Print this form to the CutePDF Printer. Rename, save and email to Sheryl.
FY16
AP Use Only:
P
Requestor Information
Requesting Organization
(NONE) Select a Club using the drop down box
Requested By
Request Date
Contact Phone
Contact email
My Club Advisor has approved this purchase request.
Messiah ID
Yes
No
Vendor Information (If you used your own funds to purchase something, put yourself as the vendor)
Vendor is Messiah Student?
Yes
No
Messiah ID
Messiah Campus Mail Box #
Vendor Name
Address
City
Contact Phone
State Pennsylvania
ZIP Code
Contact email
Have you purchased anything from this vendor before?
Yes
No
Description of Purchase and Comments About Purchase
If there are any special delivery instructions for when this purchase arrives to campus, please specify them here:
Does the vendor need payment in advance?
No
Yes
If so, when is the payment due?
Ensure that the vendor sends an invoice or written statement for payment after the purchase has been received.
Please continue to the next page of the form to list items being purchased and accounts out of which the funds should be paid.
(SGA-Funded) Student Club
Request for Payment
FY16
Items Being Purchased
Description of Item or Service
Quantity
Unit Price
Total Cost
0.00
$0.00
$0.00
0.00
$0.00
$0.00
0.00
$0.00
$0.00
0.00
$0.00
$0.00
0.00
$0.00
$0.00
0.00
$0.25
$0.00
Total Amount of Payment Requested
$0.00
Mileage Reimbursement
If your request includes mileage, please
state the destination(s) you visited:
Below, you must choose at least one org and account to pay for the items listed above. The first organization is defaulted
from page one. Once your orgs and accounts are chosen, please allocate the dollar amounts between orgs and accounts and
verify that the total equals the "Total Amount of Payment Requested" above. If you are simply using one account and one
organization (most common) then only choose Account Code 1 and put the amount of the request in the top-left amount box.
Account Code 1
(NONE) Select an Account code using the drop down box
Account Code 2
(NONE) Select an Account code using the drop down box
Account Code 3
(NONE) Select an Account code using the drop down box
Account Code 4
(NONE) Select an Account code using the drop down box
Account Code 5
(NONE) Select an Account code using the drop down box
Account (Select with "Account Codes 1-5" above)
Organization (Select 2nd & 3rd with drop-down box)
NONE
NONE
NONE
NONE
NONE
(NONE) Select a Club using the drop down box
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(NONE) Select a Club using the drop down box
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(NONE) Select a Club using the drop down box
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Account Totals & Grand Total
Org Total
Accounting is in balance.
This form is required to be updated annually as well as when new organizations are added. The last update to this form was done on
September 1, 2015 by Sheryl Ezbiansky.
(SGA-Funded) Student Club
Request for Payment
FY16
Instructions for Completed Form
Once all fields are filled out, verify that accounting amounts are in balance. If accounting is not in balance, that means that the
total of all the amounts stated for organizations and accounts does not equal the total amount requested. If accounting is in balance,
the form is ready to be submitted.
To submit the form, scan all receipts, invoices and or contracts as a PDF file. There are copier/scanners campus-wide that are capable
of scanning to PDF through e-mail. Send yourself the PDF copies of the receipts and then fill out this form. Print this file as a PDF. If
you do not have a PDF printer, contact ITS or search for CutePDF Writer online. Email this form and the receipts as PDF attachments
in an email to Sheryl Ezbiansky at [email protected].
If the IRS Required Information section below says that a form W-9 must be submitted for this transaction, the vendor will not be
paid until a valid form W-9 is on file for that vendor. Please take notice to the red text below to see if you need to turn a form W-9 in.
If you are estimating expenses, estimate high so the entire amount is approved. If your expenses exceed the amount requested, you
might have to submit a new request. If the expenses are lower than the estimate, the actual amount of the expenses is billed to your
organization rather than the full amount of the request.
After the form has been submitted, if you receive an invoice or additional receipts relating to this request, please be in contact with
Sheryl Ezbiansky at [email protected]. She will have a Purchase Order number for your request and will need PDF scans of
the additional receipts. Finally, once the expenses are settled, Accounts Payable will pay the vendor. (If the payment is to a Messiah
College employee or student, this will be paid by Payroll rather than by Accounts Payable.)
IRS Required Information for this Transaction:
No IRS Form W-9 is required for this transaction.
The section below is for use only by Sheryl Ezbiansky or other delegate authorized by the SGA Treasurer:
Purchase Order Number
Actual Dollar Amount of Expense
P