The University of Memphis
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 compensation to the individual or contractor is less than $5,000.00. Payments to the same individual or contractor for $5,000.00 or more during a calendar year (whether fragmented or paid in a lump sum) require an obligated contract established through the Procurement and Contract Services . 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. Purchase Order (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 13 is marked "Yes," describe the services below:

Date Rendered
Units of Service
(Hours/Days)
Brief Description of Services Provided (Be Specific)
  1. Department Head/Higher Authority:
    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:
    Dept Head/Higher Authority Signature   Date

  2. (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.)

    ________________________________________
    Dept Head/Higher Authority 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:
Dept Head/Higher Authority Signature    Date

II. AUTHORIZATION TO CONTRACTOR
(This authorization may be used in lieu of a written contract, if and only if, the total compensation to the individual or contractor during a calendar year is less than $5,000.)

  1. 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:

  2. 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 $ .

  3. 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.

  4. 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.

  5. 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.

  6. The term of this Authorization is from to .

  7. 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    
    ________________________________________  _______    
    Dept Head/Higher Authority Signature Date    

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

    ________________________________________  _______    
    Contractor Signature Date    

CONTRACTOR INFORMATION FOR NON-U.S. CITIZENS:
This section must be completed in its entirety.
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:

Non-U.S. citizens may be subject to 30% withholding.

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.