Independent Contractor Payment Request
All independent contractors must be approved by legal counsel. Attach legal counsel approval.
Invoices and Contracts must accompany all payment requests.
This form cannot be used for Pace employees.
Social Security No:
Name: Shaded areas to be completed by Financial Services
Address: Date: DocID:
City: Vender Code: Check No.:
State: Zip Code:
1 Payment Amount: Rate: Per:* 2 Payment Amount: Rate: Per:*
Total Hours: Total Hours:
Service Provided Service Provided
(35 Character limit): (35 Character Limit):
Index Account Index Account
Requested By: Date: Requested By: Date:
Authorized By: Date: Authorized By: Date:
* Indicate basis of rate (H=Hourly, D=Daily, W=Weekly and M=Monthly)
FINANCIAL DIVISION USE: This form is to be utilized for payment of personal services
provided by a non-Pace employee. Reimbursement of business
Accounting Approval: Date: expenses for non-Pace employees is to be done through the Travel
/ Expense Reimbursement Form.
A/P Reviewer: Date:
A/P Key Puncher: Date: