UNI Cooperating Teacher Payment Form #1
INSTRUCTIONS: THIS FORM MAY NOT BE DUPLICATED OR FAXED. TO RECEIVE PAYMENT, PLEASE FILL OUT
COMPLETELY AND RETURN TO UNI COORDINATOR BY THE END OF THE 4TH WEEK OF PLACEMENT.
FIRST MIDDLE OR MAIDEN LAST
HOME ADDRESS: check and 1099 if applicable will be mailed here (for direct deposit application, see below)
CITY: STATE: ZIP:
DAY: ( ) CELL: ( )
Semester: Circle One: 4 wks 10 wks 1st 8 wks 2nd 8 wks Full 16 wks
Please select your preferred payment: STUDENT TEACHER'S NAME:
4-6 weeks = $50
8 weeks = $100
10 weeks = $125
16 weeks = $200
Conflict of Interest Statement: Are you or your spouse employed by UNI, IA State, or U of IA? Yes ___ No ___
Does any officer, partner, or director in your company hold a position at any State of Iowa Regent Institution or any State of Iowa
government department or agency? Yes _____ No _____ If you have answered yes to either question, provide name,
position in your company, Iowa Dept or government agency or Regent Institution name.
Substitute W-9 CERTIFICATION: Under penalty of perjury, I certify that the taxpayer ID number shown on this form is correct.
I am not subject to backup withholding due to failure to report interest and dividend income, and I am a US citizen or US person. ***
Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.
*** Foreign persons: Cross out "US citizen or US person". There may be other forms or documents that need to be completed by you.
This will be coordinated at UNI and you will be notified if further paperwork is required. W9 instructions at www.irs.gov.
Direct Deposit (ACH) Authorization: Complete this section ONLY if you want electronic payments.
Agreement: I hereby authorize and request UNI to initiate credit entries and, if necessary a debit entry in accordance with NACHA rules
reversing a credit entry made in error, to my account at the financial institution named. The electronic payment data remains in effect until withdrawn by:
a) a written request to the University, or b) my death or legal incapacity, or c) the financial institution, or d) the University.
Your Financial Institution: City/State:
Bank Routing Number
This is the 9-digit number that identifies your bank. It is located in the bottom left corner of your checks before the colon(:).
Your Account Number
This number is everything after the colon (:) minus your check number.
MUST provide clearly printed e-mail address :
UNI Coordinator Signature