Signator of fund Date

Second Signature Date

Name

Senior campus Administrator (if required)

City

State ZIP

Mail to Payee Hold for pickup

Mail to: YES NO

Name

City YES NO

State ZIP

Invoice # Acct # Fund GL Acct Function

Project

Program Amount

TOTAL: $0.00 $0.00

Payee Social Security Number

REQUEST FOR WITHDRAWAL OF FUNDS (rev 2009-07)

AUTHORIZED BY:

7. IS THIS A REQUEST FOR AN HONORARIUM, CONSULTING

FEE OR CONTRACTED SERVICE PAYMENT? (If yes, attach contract

or service agreement.)

1. NAME OF FUND

2. AMOUNT OF PAYMENT

3. PURPOSE OF WITHDRAWAL (attach original documentation)

FUND #

Address

Same as Above

PROJECT #

5. SEND CHECK TO (check one): 6. IS THIS A REQUEST FOR AN ADVANCE? (If yes, original

documentation is required within 30 days of the advance being issued.)

4. MAKE CHECK PAYABLE TO:

Address

This total MUST equal the amount listed on step 2, above:

8. Complete (non-shaded) columns below, as needed.

Memos/additional information