Request for Foreign/International Currency Draft
RETURN FORM TO:
Treasury, Tax & Investments, 300 College Park, St. Mary’s Room 405, Dayton, OH 45469-1665
Date Received: _______________________
Department Name:
De
partment Contact:
Department Zip: Contact Phone:
Payee (Beneficiary) Name & Address:
Payment Support including Purpose: (Attach original
invoice, vendor’s independent confirmation of bank
account information, Form W-8BEN or W-8BEN-E )
Transfer Amount: Currency:
Department FOAPAL String:
FUND ORGANIZATION ACCOUNT PROGRAM ACTIVITY LOCATION AMOUNT
Signature Approvals (Additional signatures required if payment is above signature thresholds)
Requestor Signature
Print Requestor Name
Date
Department Head/Budget Manager Signature
Print Department Head/Budget Manager Name
Date
Dean/Vice President Signature
Print Dean/Vice President Name
Date
VPFAS Signature
Print VPFAS Name
Date