Check Request Form
STUDENT INFORMATION - STUDENT/FACULTY/STAFF COMPLETE
City, State, Zip:
IMPORTANT: Original receipts or other supporting documentation to verify the amount requested are required to process payment.
College Support for Student Expenses (STUDENT SIGNATURE REQUIRED BELOW)
Purchase of Goods/Services from Student
IMPORTANT: According to current tax laws, there may be tax implications related to the payment you will be receiving.
By law, Nazareth College must report to the Internal Revenue Service the value of certain types of support or payments you
receive over the period of a calendar year. By signing and dating this form, you affirm your understanding of the tax information
above and you assert that you have received a copy for your records. You will receive any applicable tax forms from the college
at the end of the calendar year.
Non-US citizens are subject to 30% withholding unless a Form W-8BEN or Form 8233 has been provided.
Student Name (Print):
PAYMENT INFORMATION - FACULTY/STAFF COMPLETE
APPROVER INFORMATION - FACULTY/STAFF COMPLETE
CONTROLLER'S OFFICE USE ONLY
Check to confirm a copy of this form has been sent to Financial Aid (if applicable)
Requestor Name (print):
Department Head Name (print):
Department Head Signature:
TYPE OF STUDENT PAYMENT REQUESTED
Mail Check E-Check
Enter banking information for direct deposit (E-Check) at NazNet Self Serve
SPARK (STUDENT SIGNATURE REQUIRED BELOW
All student payments will be AP Type 04