Rev 11/08
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.
Contractor Information
First Name / Middle Init. Last Name
Social Security Number Date of Birth
US Street Address
ZIP Code
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.
Work Information
Payment is for the following specific services:
Work began on: and ended on:
Total Payment Due:
Contractor Signature Date
Print Form