Request for Research Participant Payment

Request for Research Participant Payment
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The University Of Memphis Operating Procedure No.
2D:03:07D provides additional information for completing this form.

This information is necessary for IRS Form 1099-MISC. STUDENT ATHLETES CANNOT PARTICIPATE!

Participant's Name:

SSN:

Mailing Address:
(street/city/state/zip)

U.S Citizen? Yes Country if not U.S.:
(If not U.S. citizen, payment must be made through the Accounting Office because income tax withholding may be required.)

Title of Research Project:

Amount of Request $: Fund: Org: Dept: Prog: Act:

Date Rendered	Units of Service	Rate per Unit	Description of Participation

I certify that I particiapted in the above research project.

Participant's Signature_____________________________ Date__________

I certify that the person named above participated in the above research project.

Authority's Signature_______________________________ Date__________

Project Director or Approver's Signature_____________________________ Date__________

Project Director or Approver's Name:

ACKNOWLEDGEMENT OF RECEIPT OF PAYMENT
To receive immediate payment, present this form to a university cash custodian such as a window teller at the Bursar's Office, the Speech and Hearing Center Business Office, or a departmental petty cash custodian; otherwise, this form must be routed to the Accounting Office and a check will be mailed to the address above.

Received by:_____________________________

Date__________

Participant Signature

Disbursed by:_____________________________

Date__________

Petty Cash Custodian

The University of Memphis is an Equal Opportunity/Affirmative Action University.
It is committed to education of non-racially identifiable student body.