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Check Request Form Template - Excel

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Check Request Form Template document sample

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									LSUHSC NEW ORLEANS
  DIRECT PAY CHECK
      REQUEST
A DIRECT PAY CHECK IS A NON-PAYROLL REIMBURSEMENT CHECK THAT IS ISSUED WITHOUT THE
REQUIREMENT OF A LSUHSC N.O. PURCHASE ORDER. SEE BELOW FOR ITEMS WHICH QUALIFY
FOR DIRECT PAY REIMBURSEMENT.

      (1) TO VIEW THE SAMPLE COMPLETED DIRECT PAY CHECK REQUEST WORKSHEET,
          PLACE THE MOUSE ARROW ON THE "SAMPLE CHECK REQUEST" TAB AND LEFT CLICK.

      (2) TO VIEW THE SPECIFIC INSTRUCTIONS WORKSHEET, PLACE THE MOUSE ARROW
          ON THE "TEMPLATE INSTRUCTIONS" TAB AND LEFT CLICK.
         IN THIS PAGE YOU WILL BE PROVIDED DETAILED INSTRUCTIONS TO ENTER CHECK
         REQUEST DATA INTO THE DIRECT PAY CHECK REQUEST FORM.
         EACH ELEMENT OF THE CHECK REQUEST FORM IS EXPLAINED STARTING WITH
         THE FIRST ITEM AT THE TOP OF THE CHECK REQUEST.

      (4) THE PRINT COMMAND IS SET TO PRINT THE EXPENSE REPORT. SIMPLY LEFT CLICK
         THE PRINTER ICON AND THEN CLICK OK.

      (5) TO VIEW THE DIRECT PAY CHECK REQUEST TEMPLATE, PLACE THE MOUSE ARROW ON
          THE "CHECK REQUEST TEMPLATE " TAB AND LEFT CLICK. YOU WILL PREPARE YOUR
         CHECK REQUEST USING THIS TEMPLATE.

      (6) AFTER YOU HAVE COMPLETED THE CHECK REQUEST, SAVE THE FILE AS THE
         DIRECT PAY REQUEST NUMBER AND SUBMIT AN ORIGINAL PLUS ONE COPY OF THE
         CHECK REQUEST ALONG WITH ALL ORIGINAL RECEIPTS AND REQUIRED ATTACHMENTS
         TO THE SUPPLY CHAIN MANAGEMENT DIRECT PAY SECTION.


ITEMS WHICH TYPICALLY CAN BE REIMBURSED THROUGH A DIRECT PAY CHECK REQUEST ARE:

1)      PROFESSIONAL ORGANIZATION MEMBERSHIPS, BOTH INDIVIDUAL AND INSTITUTIONAL.

2)      ONE TIME PAYMENT OF A PROFESSIONAL SERVICE/CONSULTING CONTRACT.

3)      CLINICAL TRIAL PARTICIPANT PAYMENTS.

4)      CLINICAL PATIENT REFUNDS.

5)      MAGAZINE/PERIODICAL SUBSCRIPTION RENEWALS. (ORIGINAL SUBSCRIPTION
         REQUIRES A PURCHASE ORDER).

6)      REGISTRATION FEE FOR LOCAL CONFERENCES.

7)      FOOD SERVICES PROVIDED BY THE LSUHSC CONTRACT VENDOR.

8)      STUDENT REFUNDS/SCHOLARSHIPS/GRANTS/LOANS.

9)      EMPLOYEE EXPENSE REIMBURSEMENTS FOR MATERIALS OR SERVICES WITH A
         FINANCIAL VALUE BELOW STATE BID LAWS (CONTACT PURCHASING BEFORE INCURRING
         EXPENSES OF THIS TYPE)

10)     PAYMENTS TO VENDORS FOR MATERIALS OR SERVICES WITH A FINANCIAL VALUE
         BELOW STATE BID LAWS (CONTACT PURCHASING BEFORE INCURRING EXPENSES
         OF THIS TYPE)
             LOUISIANA STATE UNIVERSITY HEALTH SCIENCES
                              New Orleans Campus
DIRECT PAY CHECK REQUEST INSTRUCTIONS:
  SPECIFIC -
REFERENCE #




PAYABLE TO:

ADDRESS LINES:

DATE:

CHECK AMOUNT:

VENDOR NUMBER:


PURPOSE/JUSTIFY:

ACCOUNT:


FUND:

DEPT ID:

PROGRAM:

CLASS:

PROJECT ID:

INVOICE #:


INVOICE AMOUNT:
CREDIT AMOUNT:




DEPT CONTACT:


DEPT NAME:

AUTHORIZED BY:

APPROVED BY:

SYSTEM VOUCHER #
UISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
               New Orleans Campus
 ECK REQUEST INSTRUCTIONS:


        THIS IS A TRACKING NUMBER SIMILAR TO THE PREPRINTED REQUISITION NUMBER USED
        IN THE LEGACY SYSTEM.
        FOR PEOPLESOFT THE REFERENCE NUMBER MUST BE FORMATTED AS FOLLOWS:
        DP/DEPARTMENT NUMBER/4 DIGIT SEQUENTIAL OF YOUR CHOICE

        EXAMPLE: DP1651000A001 (DIRECT PAY REQUEST A001 FROM ACCOUNTING SERVICES
        DEPARTMENT NUMBER 1651000

        ENTER LEGAL NAME OF PAYEE IN THIS CELL

        ENTER COMPLETE MAILING ADDRESS IN THESE CELLS

        ENTER THE CURRENT DATA AS MM/DD/YY

        SPREADSHEET WILL AUTOMATICALLY SUM FROM THE INDIVIDUAL INVOICE AMOUNT CELLS

        THIS NUMBER WILL BE ASSIGNED BY ACCOUNTING SERVICES IF NOT PROVIDED BY THE
        DEPARTMENT

        ENTER COMPLETE INFORMATION

        ENTER HE 6-DIGIT ACCOUNT FOR THE EXPENSE/REVENUE TYPE (THIS NUMBER WAS THE
        OBJECT CODE IN THE LEGACY SYSTEM)

        ENTER THE 3-DIGIT FUND NUMBER FOR THIS FUNDING SOURCE.

        ENTER YOUR 7-DIGIT DEPARTMENT NUMBER

        ENTER THE 5-DIGIT PROGRAM NUMBER FOR THIS FUNDING SOURCE

        ENTER THE 5-DIGIT CLASS NUMBER FOR THIS FUNDING SOURCE

        ENTER THE 10-DIGIT PROJECT NUMBER FOR THIS FUNDING SOURCE

        THIS VALUE WILL PRINT ON THE CHECK STUB AND SHOULD BE THE VENDOR'S INVOICE
        NUMBER OR SOME IDENTIFYING INFORMATION FOR HE VENDOR.

        ENTER THE AMOUNT OF EACH INVOICE/ACCOUNT DISTRIBUTION. THE TOTAL OF THIS
        COLUMN, NET OF THE CREDIT COLUMN WILL BE SUMMED IN THE "CHECK AMOUNT"
        FIELD.
ENTER THE AMOUNT OF EACH CREDIT MEMO/ACCOUNT DISTRIBUTION. THE TOTAL OF THIS
COLUMN, NET OF THE INVOICE COLUMN WILL BE SUMMED IN THE "CHECK AMOUNT"
FIELD.

NAME OF PERSON INITIATING THIS CHECK REQUEST.   WILL ALSO BE USED BY
ACCOUNTING FOR DISTRIBUTION.

HOME DEPARTMENT NAME.   WILL BE USED BY ACCOUNTING FOR DISTRIBUTION.

SIGNATURE APPROVAL AT INITIATING DEPARTMENT LEVEL (REQUIRED).

SIGNATURE APPROVAL AT DIVISION LEVEL WHEN REQUIRED.

NUMBER ASSIGNED BY THE ACCOUNTS PAYABLE SYSTEM WHEN THE VOUCHER IS ENTERED.
                                LOUISIANA STATE UNIVERSITY MEDICAL CENTER-NEW ORLEANS
                         LOUISIANA STATE UNIVERSITY HEALTH CENTER-NEW ORLEANS
                                                       ACCOUNTS PAYABLE SYSTEM ENTRY FORM
                                                       ACCOUNTS PAYABLE SYSTEM ENTRY FORM
                                                          DIRECT PAY CHECK REQUEST
                                                                  REFERENCE #            DP1492000A01                 Revised 07/01/07

PAYABLE TO:                PROFESSIONALS ORGANIZATION                                                        DATE:                        07/01/08
  ADDRESS LINE 1           122 MILL ROAD
  ADDRESS LINE 2           SUITE 500                                                                         CHECK AMOUNT:                       250.00
  ADDRESS LINE 3
  CITY-STATE               CHICAGO, IL. 35202                                                                VENDOR NUMBER:               723456789
  (including zip code)
PURPOSE/JUSTIFICATION:    TO PAY FOR THE PROFESSIONAL MEMBERSHIP FEE OF DR. JOHN ADAMS FOR
THE PERIOD JULY, 1, 2008 THROUGH JUNE 30, 2009




                                                                                                                      GROSS                   CREDIT
  ACCOUNT          FUND      DEPT ID        PROGRAM      CLASS         PROJECT ID                INVOICE #           AMOUNT                   AMOUNT
       6             3          7              6              6             10

  535000           113      1492000         00001        37100       149200000A            12345678910000               500.00                  (250.00)




                                                                                                                        500.00                  (250.00)

JOHN ROCKER                                           3-4599
DEPARTMENT CONTACT (Please Type)                      PHONE                                                  AUTHORIZED BY (DEPARTMENT)

MEDICINE                                              MEDICAL SCHOOL
DEPARTMENT NAME (Please Type)                         BUILDING                                               APPROVED BY:(DEAN)

                            Date received                         Reroute to Sponsored Projects/Dept                          Date Reviewed


For DP Use Only                                                    send                            return    By:


Audit Timeline




SYSTEM VOUCHER #
                        LOUISIANA STATE UNIVERSITY HEALTH CENTER-NEW ORLEANS
                               LOUISIANA STATE UNIVERSITY MEDICAL CENTER-NEW ORLEANS
                                                       ACCOUNTS PAYABLE SYSTEM ENTRY FORM
                                                       ACCOUNTS PAYABLE SYSTEM ENTRY FORM
                                                         DIRECT PAY CHECK REQUEST
                                                                  REFERENCE #                                              Revised 07/01/07

PAYABLE TO:                                                                                                DATE:
 ADDRESS LINE 1
 ADDRESS LINE 2                                                                                            CHECK AMOUNT:                         0.00
 ADDRESS LINE 3
 CITY-STATE                                                                                                VENDOR NUMBER:
 (including zip code)
PURPOSE/JUSTIFICATION:




                                                                                                                   GROSS                    CREDIT

PS ACCOUNT        FUND      DEPT ID        PROGRAM      CLASS         PROJECT ID               INVOICE #           AMOUNT                   AMOUNT
       6            3          7              6              6             10




                                                                                                                           0.00                  0.00


DEPARTMENT CONTACT (Please Type)                     PHONE                                                 AUTHORIZED BY (DEPARTMENT)



DEPARTMENT NAME (Please Type)                        BUILDING                                              APPROVED BY:(DEAN)


For DP Use Only            Date received                         Reroute to Sponsored Projects/Dept                         Date Reviewed

                                                                  send                           return    By:


Audit Timeline




SYSTEM VOUCHER #

								
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