Account Request Form

							                                                           University of Pittsburgh
                                                           Account Request Form
      Complete and submit this form to General Accounting to request a new PRISM account. Incomplete forms will not be processed.
  SECTION 1
  Account Type: (Check one.)
  1 02 Operating        1 03 Cost Center *          1 04 Discretionary (Gift)     1 07 Government Student Loan
  1 02 Balance Sheet    1 03 Balance Sheet          1 09 Agency                   1 47 University Student Loan
   *A cost model must be attached for all cost centers that charge sponsored project accounts. For information, go to www.bc.pitt.edu/rca/ca_ccm.html.
  Account Title:                                                                                                        Start Date:

  Department: (Print or type the five-digit code and name of the responsible University department.)                    Expected Duration:


  Responsibility Center/School: (Print or type the two-digit code and name of the requesting department's Responsibility Center.)


  Purpose & Justification: (Print or type a brief description of the intended purpose of the account being requested. Attach copies of all
  relevant documents that specify expenditure restrictions such as program authorization memorandum, donor agreement or cost model.)




  Funding Sources: (Check all that apply; if more than one, circle the primary source.)             Estimated Annual Total:
  1 Operating Budget (Hard Money)                                     1 Rental Revenue              $
  1 Continuing Education Tuition & Fees                               1 Patent & Royalty Revenue                         IDC Code
  1 Sales & Services of Educational Activities                        1 Interdepartmental Cost Recovery ***          1 Requested
  1 Sales & Services of Auxiliary Enterprises                         1 Transfer from another University account (List account
  1 Gift ** (Specify the gift amount if presently in the University      number(s))
     holding account) $
  1 Other (Explain)
  ** For information on Gifts, go to www.pitt.edu/home/pp/guidelines/sponsored_projects_vs_gifts.pdf.
  *** For information on Interdepartmental Charges, go to www.pitt.edu/home/pp/pp_handbooks.html.
  Activities/Expenditures: (Check all that apply; if more than one, circle the primary activity.)    Estimated Annual Total:
  1 Teaching and Training (credit and non-credit)     1 Fund-Raising                                 $
  1 Curriculum Development                            1 Alumni Affairs
  1 Departmental Research (non-sponsored)             1 Intercollegiate Athletics
  1 Specialized Services To Sponsored Projects        1 Library (private departmental collection)
  1 Community/Public Service                          1 Library (institution-wide)
  1 Consulting Services                               1 Academic Computing Support
  1 Educational Media Services                        1 Administrative Computing Support
  1 Museum or Gallery                                 1 Facilities Operation and Maintenance
  1 Student Services                                  1 Safety & Security
  1 Scholarships & Fellowships                        1 Central Support Services
  1 Faculty Professional Development                  1 Central Executive Administration
  1 Administration - Department Chair                 1 Community or Governmental Relations
  1 Administration - Dean                             1 Auxiliary Services (ancillary sales to students, faculty and staff)
  1 Sponsored Projects Administration                 1 Other (Explain)
  1 Student Organizations/Activities
  Overdraft Account: (If requesting a Discretionary or Agency account, you must provide an Operating (02) account to which
  overdrafts are to be charged.)

                           DO NOT COMPLETE THIS SECTION - FOR GENERAL ACCOUNTING USE ONLY
  Account        Entity       Department         Subcode          Purpose            Project          Reference        Future Use
  Number:                                         xxxx                             000000             xxxxx             00000
         Department            Function        Resp Center     Senior Officer    Creation Date                                         Entity 03 OH Rate
         Attributes:                                                                                                                                     %
          Purpose              Function        Endow Type       Endow Pool       Creation Date                                               Excludes
         Attributes:                               00               99

Account Request Form
Updated 4/6/2007                                                            Page 1 of 4
                                                             University of Pittsburgh
                                                        Account Request Form (Continued)
                                             Account No. ___________________________________
  SECTION 2
  Financial Report Distribution:
  Name - Recipient 1                                                                          SSN (Last four digits only)
                                                                                                     XXX-XX-
  Campus Address


  Check reports requested:
                            1 FGAR310 Level I - Balance Sheet                1 FGAR321 Level II - Financial Report
                            1 FGAR320 Level II - Balance Sheet               1 FGAR322 Level II - Financial Report (Ref. Sort)
                            1 FGAR311 Level I - Financial Report             1 HLDR310 Labor Distribution By Account

  Name - Recipient 2                                                                          SSN (Last four digits only)
                                                                                                     XXX-XX-
  Campus Address


  Check reports requested:
                            1 FGAR310 Level I - Balance Sheet                1 FGAR321 Level II - Financial Report
                            1 FGAR320 Level II - Balance Sheet               1 FGAR322 Level II - Financial Report (Ref. Sort)
                            1 FGAR311 Level I - Financial Report             1 HLDR310 Labor Distribution By Account

  SECTION 3                                                                                                            FI USE ONLY
        IDC Code Information:                         (Type of Charge)                                         Approved (RCA):
                                                                                                               IDC Code (FIA):
      IDC PROCESSORS ONLY




                            Debit Subcode(s):                               Credit Subcode(s):

                            Preparer:                                       Approver:
                            Name (Print or Type)                            Name (Print or Type)

                            Address                                         Address

                            Phone                                           Phone

                            E-mail Address                                  E-mail Address

  SECTION 4
  PRISM Access - To request online access for a new department value or IDC entry, go to the PRISM User Forms web page at
  www.bc.pitt.edu/prism/PrismForms/index.html and follow the PRISM Department User Access instructions.
  Responsible Person:
  Name (Print or Type)                                                      Title

  Address                                                                   Phone                              Fax


  E-mail Address

  Certification:
  I herby certify and acknowledge that as a responsible person for the above named account, I agree that the account will be operated in accordance
  with all University of Pittsburgh policies and procedures, that for restricted or agency accounts available revenue will be in excess of expenses
  at all times, and that the account is subject to termination by the University at any time.
  Signature of Responsible Person                                                                              Date


  Approval: Name of Vice Chancellor/Dean or Responsibility Center Business Manager (Print or Type)


  Signature of Vice Chancellor/Dean or Responsibility Center Business Manager                                  Date


Account Request Form
Updated 4/6/2007                                                         Page 2 of 4
                             Account Request Form Instructions

     SECTION 1
     Account Type: Indicate the type of account being requested by checking one of the following:


           02 Operating – represents core University operations that are funded primarily by tuition, the
          State appropriation, and Education & General sales and services. Departmental “hard fund”
          budgets are allocated annually as part of the University’s Planning and Budgeting Process

           02 Balance Sheet – Assets and liabilities associated with core University operations and
          includes a purpose code

           03 Cost Center – “Break even” activities that are supported by revenue from external customers
          and/or interdepartmental cost recovery from other University departments

               1) Specialized Service Facility – specialized service provided primarily to sponsored
               research, e.g., Central Animal Facility and DNA Sequencing

               2) Central Support Services – Provides support for departments and programs, e.g.,
               Telecommunications, Motor Pool, Computing Services, Central Printing, Mailing Services,
               Inventory Stockrooms, and Central Copying Services

               3) Informal and Professional Educational Programs – Degree/non-degree programs for
               Professional Certification or self-improvement, e.g., Continuing Ed; Conferences and
               Seminars; and Dental Students providing services

               4) Auxiliary Enterprises – Provides services to individual students, faculty or staff, e.g., Food
               Services, Parking and Transportation, Bookstore, and Property Management
           03 Balance Sheet – Assets and liabilities associated with cost center operations and requires a
          purpose segment

           04 Discretionary – Funds restricted by donors and other external agencies for specific
          purposes, programs, departments or schools

           07 Government Student Loan – Government-funded revolving student loans (e.g., Perkins
          Loans and Stafford Loans)

           09 Agency – Resources held by the University (the Agent) for organizations or entities (the
          Principal) external to the University (e.g., a student, staff or alumni association; a professional or
          scientific organization in which faculty or staff are officers or editors) that are not subject to the
          University's control

           47 University Student Loan – Revolving loan funds that are established by gifts from outside
          donors or board designated funds

     Account Title: Print or type the title of the account being requested. Note that PRISM allows 240
     characters in this field but only 30 will be shown on most financial reports.

     Start Date: Print or type the earliest date by which the new account is needed.

     Expected Duration: Print or type the expected life of the account (e.g., “Indefinite,” “FY 20XX” or “FY
     20XX through FY 20XX”).

     Department: Print or type the five-digit code and name of the responsible University department.
Account Request Form Instructions
Updated 4/6/2007                                      Page 3 of 4
     Responsibility Center: Print or type the two-digit code and name of the requesting department’s
     Responsibility Center.

     Purpose/Justification: Print or type a brief description of the intended purpose of the requested
     account. Attach copies of all relevant documents that specify expenditure restrictions such as formal
     program authorization memoranda or donor agreements.


     Funding Sources: Indicate the type of funding source(s) expected to support the expenditures of the
     requested account by checking all funding sources that apply. If more than one funding source is
     identified, please circle the primary funding source. If the funding source is a gift and has been received
     and deposited to the University’s restricted gift holding account, please specify the amount. Then enter
     the estimated annual total of all funding sources identified. (NOTE: If departmental Cost Recovery has
     been selected, please indicate in the corresponding box if a new IDC Authorization code is needed for
     processing charges. If a new code is being requested, Section 3 of this form must be completed.)

     Activities/Expenditures: Indicate the type of activity or activities expected to be supported through the
     expenditures of the requested account by checking all activities that apply. If more than one activity is
     identified, please circle the primary activity (i.e., largest proportion of expenditures). Then enter the
     estimated annual total expenditures of the requested account.

     Overdraft Account: If requesting a Discretionary or Agency account, you must provide an Operating
     (02) account to which overdrafts are to be charged.

     SECTION 2
     Financial Report Distribution: For each recipient, print or type their full name, the last four digits of
     the social security number, and the campus mailing address of the recipient(s). Check off all of the
     reports to be distributed for this account.

     SECTION 3
     IDC Code Information: List the nature or type of charges. Provide the debit (charge) and credit
     (recovery) subcodes that will be used - leave blank if you are not certain of the proper subcode usage.
     You will be notified of the appropriate subcode usage. Clearly print or type all preparer and approver
     information as indicated.

     SECTION 4
     PRISM Access: To request online access for a new department value, go to the PRISM User Forms
     web page at www.bc.pitt.edu/prism/PrismForms/index.html and follow the PRISM Department User
     Access instructions.

     Responsible Person: Print or type the full name, working title, mailing address, telephone number, fax
     number, and e-mail address of the authorized faculty or staff employee who assumes responsibility for
     the proper administration and monitoring of the requested account.

     Certification: The responsible person must sign and date the form.

     Approval: Print or type the name of the Provost, Vice Chancellor, Dean, or Responsibility Center
     Business Manager approving the account request and report distribution. The Vice Chancellor, Dean,
     or Responsibility Business Manager must sign and date the form.


     Note: General Accounting will not process incomplete account request forms, including forms without
     proper authorization.


Account Request Form Instructions
Updated 4/6/2007                                     Page 4 of 4