Revised 10/2013
Accounts Receivable
1845 Fairmount Box 38
Wichita, KS 67260-0038
(316) 978-3070
WSUAccountsReceivable@wichita.edu
REQUISITION FOR LOCAL BANK CHECK
Name of Bank: Commerce Bank Bank Account: Imprest Bank Acct #: 13s
It is requested that a check from the above named bank account be drawn in favor of payee as shown. Imprest Fund account is no longer used to
issue checks to Vendors. The payee will be a WSU Employee requesting the advance. Fill out all
*
D
ate: __________ *Amount: $____________________ *myWSU ID: ________________________________
*WSU EMPLOYEE Payee: __________________________________________________________________________
*
Description of Request: __________________________________________________________________________
*
When Will Imprest be Reimbursed: _________________________________________________________________
I hereby agree to repay this advance within 30 days. I acknowledge and understand that failure to repay this advance could result in being sent
to WSU collections. I hereby acknowledge, consent to and specifically authorize the University to deduct said amount from my university
paycheck by means of a payroll deduction, said authorization being made pursuant to Section 3.14 (Withholding and Setoff) and Section 13.07
(Payroll Advances) of the WSU Policies & Procedures Manual. I also understand and agree that in accord with University policy, I will not be
eligible for further advances while the balance remains unpaid. NOTE: If a grant participant owes the State of Kansas, I am fully aware that I
am responsible for repayment.
*Requestor’s Signature: ______________________________________________________________ Phone #: _______________________________
I hereby agree to repay the advance with department money in the event there is failure of repayment from original advance.
*Budget Officer’s Signature: ______________________________________________ Phone #: _________________________
R
eimbursing Fund: __________________ Org: __________ Acct: _________________
I
f Grant Funding then ORA approval will be needed:
*ORA Funding Approval: _________________________________________________ Phone #: _________________________
Mail or bring original request with original signature to: Accounts Receivable, Campus Box 38, Jardine Hall, Room 201.
..…Do Not Change Funding…..
Accounts Receivable Use Only
A/R Signature: _______________________________________ RADV Completed on TSAAREV ( )
A
pproved By: ________________________________________ Copy of Request in Pending File ( )
Check No.: ___________________ Date Issued:____________
