LIMITED SERVICES ENGAGEMENT FORM
Organizational units may submit this form with an A114 Request for Payment, for services rendered by an
individual contractor. This form may not be used for:
* a service period exceeding one continuous week per year.
* a current or former UC employee.
* a UC student enrolled within the past two years (minimal exceptions allowed with prior approval
of Director, Tax Compliance -- see financial policy 2.3.1, Payments to Individuals for Services).
* payment of an academic scholarship or fellowship.
First Name / Middle Init. Last Name
Social Security Number Date of Birth
US Street Address
If foreign address, please enter here:
Is Contractor a US citizen?
Yes No Yes No
If not, is Contractor a Lawful Permanent Resident
("green card" holder)?
NOTE: If the answer to BOTH of the above questions is "No," then the organizational unit should also complete and
attach the Foreign Visitor Supplement.
Payment is for the following specific services:
Work began on: and ended on:
Total Payment Due:
Contractor Signature Date