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Request for Special Services
SS #:
For one time services to individual, not EMPLOYEES or STUDENT ASSISTANTS, of the university. Please allow 10 working days for processing. It is customary to pay claimant at conclusion of service.
see
instructions
BUSINESS UNIT:
BKCMP
BKASI
BKFDN
BKSTU
BKFFR
BKSPA
VENDOR:
DATE:
NAME:
SSN#:
(MANDATORY)
TITLE:
TOTAL AMOUNT
DUE:
NOT TO EXCEED $2,500.00
ADDRESS:
(MANDATORY)
CITY:
PHONE:
STATE:
ZIP:
DESCRIPTION OF
SERVICES:
TO BE
PICKED UP
FROM CASHIER'S WINDOW
BY DEPT. REP.
Print name & extension
DATE OF
SERVICES:
TO BE
MAILED TO
ABOVE ADDRESS AFTER COMPLETION OF SERVICES.
DISPOSITION OF CHECK:
I understand that I am not an employee or agent of the the above mentioned Business Unit, that I am solely liable and responsible for all Federal and State taxes, that I am not covered by Worker’s Compensation or Unemployment Insurance or eligible for any fringe benefits, and that I agree to hold this Business Unit harmless from any liability resulting from work performed relative to this agreement. I further agree to indemnify and/or defend the Business Unit in any legal proceedings that arise out of the performance of this contract by any party.
__________________________________________________
Claimant Signature
NOTE: Make sure values on form are correct as VALUES ARE CLEARED BEFORE PRINTING AND FORM IS REFRESHED!
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Department Authorization:
I hereby certify that the services described above have been completed and that payment is now requested.
Requested by
__________________________________________________
Requester Signature
Approver Print name
__________________________________________________
Department Approved Signature
Fund:
Department:
Account:
Program:
Project:
Class: