The University of Memphis
Request for Research Participant Payment
This information is necessary for IRS Form 1099-MISC. STUDENT ATHLETES CANNOT PARTICIPATE!
Participant's Name:
Banner ID#:
Mailing Address:
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:
Received by:_____________________________
                                   Participant Signature
Disbursed by:_____________________________
                                   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.