Icertifytheseexpensesareallowableandincurredforthe
officialbusinessofBerkeleyLabinaccordancewithpolicy.
Theexpensesclaimedarenotreimbursedbyothers.
Date:
Employee / Payee Information
PaymentExplanation/BusinessPurpose/Remittance AdviceInformation
Prepared By:
Payee’s Signature (not required for vendors)
Approver’s Signature
Contact / Approver Information
ProjectID
TOTAL ACTUAL COST:
ResourceCategory
Invoice Date
Invoice No.
Total Amount ($)
Icertifytheseexpensesareallowableandrepresent
officialBerkeleyLabbusinesstobechargedtothe
projectslisted.
(cannot be requesting employee)
Date:
PrintNameofApprover(must be authorized in the SAS)
OCFO Approver
Event/Meal Costs
EVENTID (fromEventApprovalDatabase):
ORIGINAL approved estimate TOTAL: $
FOOD AND BEVERAGE COSTS FOR ONSITE EVENTS
(incl. tax & tip):
Was the TOTAL ACTUAL COST per person/per meal
within the allowable limit?
Preparer’sPhoneNo.:
Yes No
*
Onsite
Allowable
Limits
(Delivery
Charges Do
Not Apply)
*Provide a brief explanation if TOTAL ACTUAL COSTS
on this RFIC exceed the allowable limit or if the costs
exceed the approved budget/estimate by $250 or more.
BusinessAddressorMailstop:
MailingAddressifDifferentfromAbove:
Trip Number (if applicable): 
Payee: Date:
Employee ID (if applicable):
Office of the
Chief Financial Officer
RFIC
RequestforIssuanceofCheck(RFIC)Form
1. Submit to Accounts Payable, Non-PO Desk, Mailstop 971-AP
2. Includeoriginalitemized receipts
3. Vendor must have Form W-9 (U.S. vendors) or
Form W-8 BEN (Foreign vendors) on file with LBNL prior to payment
Page 1 | Rev:12/2012
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