Updated 6/27/18
Payee: ________________________________________ Date: ________________
Account Number: _______________________________ Amount: ___________________________
Requisition #:_____________________________ PO # (if available):____________________
For the following goods or services furnished to the District:
(In general terms describe what was purchased, and why/for what. For travel list the date and name of travel. If for meal money advance,
provide a breakdown of amount (day or meal) x number of people x number of days), and attach a list of attendees:
The check for this payment/reimbursement should be (select ONE):
Mailed to the Payee at (PRINT LEGIBLY):
Street Address: _________________________________________ Unit/Apt #: _______________
City: ________________________________ State: _______ ZIP: _____________
Held for pick-up in the Payroll window (option is for Cerritos College Employees with a phone extension only, no cell #’s):
Call ______________________________ (name) to pick up check at ____________ (extension).
Supporting documentation:
Original, itemized receipts/invoices/agreements are required.
All expenses related to travel must have a copy of the approved Conference & Travel Request of the advisor attached.
All receipts for travel meal reimbursement must identify the meal (breakfast/lunch/dinner), and who the receipt costs apply to,
written on the back of the receipt. Meals are reimbursed at a $10 breakfast, $14 lunch, $18 dinner maximum.
Scholarship recipients and those receiving stipends/honorariums must provide a W-9 form to report taxable income. It must be
attached to this claim statement (if applicable).
Claim Statements, all supporting documentation, and the requisition cover sheet if SpendMap process completed by a requisitioner
other than Student Activities, must be submitted to the Student Activities Office for processing.
Club Advisor (reqd for clubs)
College Manager