Research Corporation of the University of Hawaiʻi

Authorization for Payment Form
Submit original invoice with this form
Date
RCUH Policy 2.702 and 2.703
Payee’s Name
Payee’s Permanent Address, Street/PO Box, City, State, Zip
Direct Inquiries on This Request To
Phone Number
Payment Req. No. Vendor Code
Document Number
FA Staff to Review
Line Project #
1 2 3 4 5
Sub Project
Budget Category
Service
Description
Amount
Sub Budget Category Date
GRAND TOTAL
Reasons for Payment (Including Period Covered, Rate of Compensation, Reference to Letters)
PROJECT PAYMENT APPROVAL: I certify that services have been rendered and/or that the materials, supplies and incidentals have been received in good order and condition and are in direct support of the program as indicated in the project number block.
Signature
Principal Investigator
Remittance Information:
Remittance Advice
Line Invoice/Reference Number
Date
Amount
Signature Date Fiscal Administrator
If the mailing address is different from above, fill out the fields below. Otherwise, the check will be mailed to the address above.
1 2 3 4 5
Name
Attn.
Street
(required)
City, State
(required)
Zip Code
(optional)
Return this remittance advice and check to fiscal office.
TOTAL
Questions on Remittance? – Call
Name
Phone Number
– (required)

Equipment Inventory:
1. DESCRIPTION – Use generic names; (e.g. 3COM CELLPLEX = Interface card)
2. BRAND NAME & MODEL NUMBER – If none, state NONE
3. SERIAL NUMBER – If none, state NONE
4. COST OF ITEM
5. BUILDING NAME AND ROOM NO. (Location of equipment)
6. TITLE/OWNERSHIP
7a. NAME OF PREPARER
7b. PHONE NUMBER OF PREPARER
8. EQUIPMENT COMPONENT: IF additional component and Cost is >=$1,000 and item will be incorporated or attached to a host/parent equipment item, provide Decal# or PO# of host/parent Standalone.(If not applicable, state N/A)
9. FABRICATED EQUIPMENT: (a) If initial purchase provide end product name (b) If addition to fabrication, provide Decal# or PO# of Initial fabrication purchase (If not applicable, state N/A in both (a) and (b))
10. EQUIPMENT RECEIVED DATE
University of Hawaii Fed. Government Other Agency
University of Hawaii Fed. Government Other Agency
University of Hawaii Fed. Government Other Agency
University of Hawaii Fed. Government Other Agency
University of Hawaii Fed. Government Other Agency
Item #1
Item #2
Item #3
Item #4
Item #5
(a) Product Name
(b) Decal# or PO#
(a) Product Name
(b) Decal# or PO#
(a) Product Name
(b) Decal# or PO#
(a) Product Name
(b) Decal# or PO#
(a) Product Name
(b) Decal# or PO#
If the Equipment Inventory form has not been completed, please click the following:
I will complete and submit an Equipment Inventory form manually and forward it to my Fiscal Office who will then forward it to the RCUH Central Office.
Internal Comments