Payment Request
This form is to request reimbursement or payment to vendor of expenses related to program and scholarship funds. Complete all sections and provide either an invoice or a receipt from the vendor with
this form and return to Institutional Advancement, Learning Resource Center, B109. As a 501-c3 nonprofit organization MCCF is exempt from paying taxes and thus does not reimburse sales tax
for MCCF-related purchases. The Tax exempt form is in Form Depot under MCC Foundation, provide it to the retailer/vendor before cashing out. Hard copies are available in LRC B109 or B114.
Please allow two weeks for processing payment requests. Questions? Call 860-512-2903.
PAYMENT REQUEST INFORMATION
Date of Request
Select only one method of delivery
Amount (please read notation below)
n Mail check to address listed below
n Transfer funds to MCC — checks payable to MCC
n Pick up check in LRC B109 (pickup information required, indicate below.)
Pick Up Name
Phone/Email
As a 501-c3 nonprofit organization MCCF is exempt from paying
taxes and thus does not reimburse sales tax for MCCF-related
purchases. The Tax exempt form is in Form Depot under MCC
Foundation, provide it to the retailer/vendor before cashing out.
Hard copies are available in LRC B109 or B114.
Payee
Number and Street
Apt. #/Building
City
Mailing
Address
Fund
Fund Account Number
(see back)
Usage
Description
n
Check if MCC employee
State Zip
Fund Name
Invoice attached?
n
Yes
n
No If no, explain.
AUTHORIZATION
Requester/Program Manager* Signature Printed name
Date
Supervisor* Signature Printed name
Date
MCCF Executive Director Signature (if not Programming Authority)
Printed name
Date
MCCF Treasurer Signature (if $2,500 or more)
Printed name
Date
* Requestor and approver cannot be same person.
FOR OFFICE USE ONLY
Date Mailed: _____/_____/________ Date Picked Up: _____/_____/________
IA Initial: ____________________ Pickup Initial: ____________________
November 2019/PR
