Date Enter the current date MM-DD-YY.
Name Enter payee name.
Honorarium Check Request Form Address Enter payee address.
Social Security Number Enter payee social security number.
To be completed by department:
Check payable to: Date: Type of Service rendered Describe the type of service rendered (speaker, proctor, tour
Name host, guest musician, etc.)
Address Account Number Enter the twelve-digit account number
X-X-XXXXX-XXXXX. Incomplete or innacurate account
Social Security Number numbers will necessitate returning the Honorarium Check
Type of Service rendered Requisition Form for clarification and will cause a delay in
issuing the check.
Payment for 12-digit account number Amount
X-X-XXXXX-XXXXX Amount Enter the amount to be paid for each line item. A Travel
Honoraria Expense Report must be filled out for travel reimbursements
Travel (if any)¹ ² and attached to the Honorarium Check Requst along with
Other expenses (if any)² related original receipts.
¹ Travel Expense Report must be filled out and attached Total $ -
² Receipts/Invoices must be attached Total Enter the total amount to be paid. The check will be
Check to be sent to payee? Yes No written for this amount.
if "no" to be sent to __________________________________________________________________________________
Check sent to Payee? Indicate whether the check is to be sent to the payee
Signatures: Phone Date named above.
Purchaser Purchaser The signature of the purchaser is required here.
Budget Officer The signature of the budget officer is required here.
Return completed form to Accounts Payable Honorarium Check Requisition Forms will not be
For Accounts Payable Use: processed without budget officer signature.
Approval for payment: Initials Date
A/P: _________ ________ Date received A/P Use for See www.calvin.edu/admin/fsrv/honorpay.htm
Controller: _________ ________ Voucher number
Return Completed form to Accounts Payable