ATU REQUEST FOR CHECK DATE:_________________
Honoraria Game Officials Refunds Stipends Agency Funds Other
Supporting documentation MUST be attached to the Request for Check Form
OR
If no documentation is available, this form MUST be signed by the Payee
AGENCY FUND REQUESTS must be submitted to the Accounting Office, Old Art Bldg, Room 312 for
verification. The Accounting Office will forward to the Disbursing Office for processing.
All other check requests are to submitted to the Disbursing Office, Administration Building, Old Art Bldg, Room
302.
Check Requested By: ________________________________________________________
(Department or Office)
FOAPAL #:
______________ ___________ ____________ ____________ ___________
Index
Fund
Organization Account Program
The vendor block must be
completed before check
request will be processed.
_________________________ RA_______
Vendor Number
/T Number
Vendor Address No.
Description of
Services/Goods OR
Reason for Refund:
____________________________________________
____________
Amount of Check
$______________________
Requested By: _____________________________________
(Signature)
Approved By:
_____________________________________
(Signature of Immediate Supervisor)
Signature of Payee: _____________________________________
(If required. See above)
Form ATU-086
Revised July 2013
Check Payable To:
____________
_
___________
______________________________
__
Send Check To Address
: ____________________________________________
____________
_
____________________________________________
___________
*Checks not mailed, must be picked up by the payee only.
T
