A&F, Financial Services, November 6, 2018
II. STATEMENT OF ACTIVITY - THIS SECTION TO BE COMPLETED BY CAMPUS REPRESENTATIVE
Select all applicable activity that is the best description of the student payment or provide a description in the line provided below:
Reimbursement Study or Research ParticipantInterview Payment
Tutoring Service
Orientation Event Worker
Is this payment related to an academic requirement or related to the student's academic attainment?
Will the participant be required to perform services in order to obtain the payment?
Last Name
I. RECIPIENT INFORMATION
Net ID:
First Name
MI
Address
Zip Code
E-mail
Phone #
City State
Amount:
Including today's activity,
have you received payments from the University in the amount of $600 or more during this calendar year?
Yes No
Yes No
Yes No
If you are a CSUEB student, please read the important acknowledgement below:
I certify that I am aware that receipt of this payment/award or prize may impose restrictions on my receipt of other financial benefit from the
University or US Government funds, and/or may have tax implications. In addition, I will immediately notify the Accounting Services
Department of any change in the information stated herein. I understand that it is my responsibility to contact the Financial Aid Office if I have
questions about how and if this will impact my financial aid package.
DISCLAIMER: The University does not assist in tax preparation, act as a tax consultant for individuals or entities, provide tax advice, and
cannot answer your tax questions. Please consult a tax professional or a financial planner who is proficient with taxation for assistance with
your tax questions.
*US Citizen/Permanent Resident?Currently Enrolled Student?
(If applicable)
Please submit completed form to Accounts Payable or ORSP as appropriate to meet requirements for CSUEB
Students and Non-students (Non-CSUEB Employees) for cash equivalent/payment reporting purposes.
ACKNOWLEDGEMENT OF RECEIPT FORM
*Note that payments for Non-US Citizens or Non-Permanent Residents are typically processed via the Accounts Payable department.
Applicable withholdings will be applied as appropriate.
Award/Prize
III. DOCUMENT SUBMISSION - THIS SECTION TO BE COMPLETED BY ACCOUNTING SERVICES / ORSP
1042-S 1099-MISC, box 7
1099-MISC, box 31098T
N/A
Yes No
Yes No
Department/PI Approver Name:
Signature
Recipient Signature
Date
Date:
Other, please explain:
Forwarded to Human Resources on: Forwarded to Accounts Payable on:
Forwarded to AP/Financial Aid on:
Forwarded to Student Finance on:
Please Explain:
Administrator Name:
Signature Date:
(AP to notify Financial Aid)
