The University of Memphis
Request for Research Participant Payment
Click here for online help.
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:
Banner ID#:
Mailing Address:
                                    (street/city/state/zip)
U.S. Citizen or Permanent Resident? Yes Country if not U.S.:
(If not U.S. Citizen or Permanent Resident, payment must be made through the Accounting Office because income tax withholding may be required.)
Title of Research Project:
Amount of Request $: Fund: Org: Account : Program: Actitity:
Date Rendered Units of Service Rate per Unit Description of Participation

I certify that I participated 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.