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Disbursement Fillable (Central Connecticut State University)

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Disbursement Type
Check One:
Payment for PSA #_______________ Final Payment?
Refund/Reimbursement
Payment for Services/Honorarium less than $3,000
Membership/Subscription
Stipend Payment
Other:
Payee Information
Name:
Is the Payee a current state employee? Yes ______ No _____
Disbursement Information -Please provide detailed information
Date:
Funding Information
Amount
$
$
$
Grant Funding Approval
All use of grant funds MUST be
approved by the Grant's Office: Date:
Revised 09/26/12
Date
Requestor's/Project Director's Signature:
Disbursement Form
Banner Account
Banner Index
Central Connecticut State University
Address:
Budget Authority Signature
REQUIRED: If this disbursement is for any type of service performed, including guest lecturer, entertainer,
honoraria please indicate the date(s) the service was performed:
_______________________________________
Please note: If using the Disbursement Form only to pay a PSA, I understand that I am responsible for ensuring compliance with State and Federal laws, University policies, and that
this payment is not for temporary office or other bargaining unit work. I have paid particular attention to the appropriate use of independent contractors. I also understand that audit
questions will be referred to me for response. I certify that the services on the above referenced PSA have been rendered and I authorize payment in the amount specified below.
(Specific Services for PSA's must be listed below when a PSA Form (CO-802A or CCSU-802A) was not submitted). If I am a project Director and I am picking up a guest speaker or
entertainer's check prior to the performance
, I certify that I will not allow the check to be released until the services have been satisfactorily provided to CCSU. In the event this does
not occur, I agree to return the check to the Business Office the next business day.
(Payee's Home Address, not department address at CCSU)
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No
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Completed 22 July 2020

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