Request for Payment to Individual or Contractor

Request for Payment to Individual or Contractor
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This authorization may be used in lieu of a written contract if, and only if, the total amount of compensation is less than $2,000.00. Payments to an individual or contractor for $2,000.00 or more during the course of a single calendar month (whether fragmented or paid in a lump sum) require an obligated contract established through the Purchasing Department. This form is sent to the Accounting Office any time a payment is requested to be made to an individual regardless of the amount. A form must be completed for each individual to be paid. The form is prepared by the requesting department and is used to secure approval of the authorization and to process the payment. Payments cannot be made to any University or State employee (which includes full or part-time faculty, staff) under this procedure.

I. GENERAL INFORMATION
(This information is necessary to complete IRS Form 1099-MISC. Lines 1-8 must be completed.)

1.	Name of Payee:
2.	(a) U.S. Social Security Number: OR (b) Federal Tax ID Number:
3.	Local Address:
	street/city/state/zip+4
4.	Permanent Address:
	street/city/state/zip+4
5.	Telephone Number:
6.	Fax Number:
7.	E-mail Addrress:
8.	Is payee a U of M student? Yes No
9.	U.S. Citizen? YES If not, state country of citizenship (If payee is not a U.S. citizen, withholding may be required. Please complete IRS Form 8233 if individual is not claiming residence in U.S. or IRS Form W-9 if individual is claiming residence in U.S.)
10.	Total Amount $ 11. Index Number/Acct Code -
12.	Obligation Number (If none, Section II below must be completed.)
13.	Are services being performed? Yes No (If "Yes," complete Section A. If "No," complete Section B.)

A. If Item 10 is marked "Yes," describe the services below:

Date Rendered	Units of Service (Hours/Days)	Brief Description of Services Provided (Be Specific)

Department Head/Project Director:
This is to certify that the payee identified above was authorized to perform services in accordance with U of M Operating Procedure Number 2D:03:07B and services were rendered in accordance with a contract dated or the Section II, "Authorization to Contractor" and payment for services should now be made.

________________________________________ Department Name:
Department Head Signature Date
(Complete only if check is requested in advance of services.)
I hereby request the check to be prepared in advance to give to the contractor upon completion of services. I certify that the check will not be released until services have been completed in accordance with the above-identified contract of Section II on the reverse hereof. (Attach statement explaining the reason the check is needed in advance.)

________________________________________
Department Head Signature Date

B. If Item 10 is marked "No," describe the purpose of the payment:

This is to certify that the payee identified above was authorized to receive payment.

________________________________________ Department Name:
Department Head Signature Date

II. AUTHORIZATION TO CONTRACTOR
(This authorization may be used in lieu of a written contract if, and only if, the total amount of compensation is less than $2,000.00.)

This is to authorize to perform the following services:
(Contractor's Name)
Detailed description, including type,scope, duration, form, quality, place, size, time, purpose, and identification of concerned University department:
Contractor shall be compensated for services rendered.
(Rate of Compensation: hourly, daily, etc.)
Payment will be made only after services have been performed. In no event shall the liability of the University under this authorization exceed $ .
The Contractor within the past six months has not been and during the term of this Authorization will not become an employee of the State of Tennessee which includes full or part-time faculty, staff, student employees or graduate assistants. The Contractor shall not directly or indirectly pay any of the compensation to any officer or employee of the University or the State of Tennessee.
No person on the grounds of disability, race, color, religion, sex, veteran status, creed, age, or national origin will be excluded from participation in, or be denied benefits of, or be otherwise subject to discrimination in the performance of this Authorization, or in the employment practices of the Contractor.
The Contractor, being an independent Contractor and not an employee of the University, agrees to protect and hold harmless the University from any and all liability not specifically provided for in this Authorization.
The term of this Authorization is from to .

This Authorization may be terminated by either party by giving written notice to the other, at least days before the effective date of termination. In that event, the Contractor shall be entitled to receive just and equitable compensation for any satisfactory authorized work completed as of the termination date.

________________________________________	_______	________________________________________	_______
Requester/Initiator Signature	Date	Dean/Director Signature ($500.00-$2000.00)	Date
________________________________________	_______
Department Head Signature	Date

I agree and accept the terms of this contract and any attached addendum. (Required if fee over $100.00)

________________________________________	_______
Contractor Signature	Date

CONTRACTOR INFORMATION:
U.S. Citizen? Yes No

If No, state country of citizenship Passport number Exp. Date

Type of Visa Dates at U of M: From to

Any prior visits to the U.S.?
If Yes, please list entry & exit dates, immigration status/Visa type, and primary purpose on separate sheet. Each visit should be listed.

Is the activity to receive the honorarium to last more than nine (9) days?

Have you received honorariums from more than five (5) organizations in the last six (6) months?

U.S. Social Security # or Federal Tax ID #

Permanent Address:

Classification: (select one)
Individual(I) Not-for-Profit Corporation (N) Foreign Individual (F) Medical/Health Corporation (M)
Sole Proprietorship (I): Owner's Name: Partnership (P) Sub-Chapter S Corporation (S)
Tax Exempt Association, Club, Religious, Charitable or Education Organization (O) Corporation

Check if Applicable: Small Business ($500,000 or less annual sales; 9 or less employees) Minority Business (51% minority owned and managed)

INSTRUCTIONS : Give two copies to Contractor. Contractor must sign and return one copy. Complete all sections of Part I. Send original to the Accounting Office.