Payment Request Form

By submitting this form, you authorize the designated amount to be paid from your AP account

Upload invoice or receipts to be paid or reimbursed. All reimbursements and vendor payments must have corresponding receipts/payments submitted here before payment can be made.

Drop files here or

Date Submitted*

Your Name*

First Last

Name of Your Organization (Alliance Partner name)*

Your Email*

Your Phone*

Payment Request*

Must submit receipts and invoices for reimbursements and vendor payments - use the file upload above.

Reimbursement request (for out-of-pocket expenses)
Vendor Payment (for goods or services Vendors from 3rd party, including contract labor)
Contract Labor
Mileage Reimbursement (mileage driven for mission purposes, not commuting)
Funds-In-Advance (requesting a check in advance of purchase, this is rare)

Payee Information

For reimbursements, mileage, contract labor, and vendors

Payment Method*

Direct Deposit (preferred)
Check by mail

Payee Type*

Person
Business/Organization

Name of person to receive the Direct Deposit*

Make check payable to:

Payee Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Update Address?

Check if this address is updating the information we previously had on file

For Direct Deposit

For each person or company who is to be paid by direct deposit, we must have a signed Direct Deposit Authorization Form submitted by the Executive Director giving us permission to set up a direct deposit payment. If you do not have one on file for this payee - see the statement in red at the top of the page. The form must be submitted before a direct deposit can be made.

*

Check here to confirm a Direct Deposit Authorization has been submitted

Accounts and Designations

Tell us what expense account(s) to use to record your reimbursement, vendor payment, mileage, or advanced funds. List Accounts Separately: (refer to your AP Chart of Accounts for account numbers) Use the + button to add additional rows IF YOU AREN’T SURE WHICH ACCOUNT TO USE, WRITE A DETAILED DESCRIPTION AND WE WILL CHOSE THE APPROPRIATE ACCOUNT

*

AP Account	Account Number	Amount	Description

If you don't know what account to use above, write a detailed description so we can choose the appropriate account

Mileage Reimbursement

For Mileage Reimbursement: Please complete the Payee Information and Payment Method sections on page 1. Then use the formula below to find the total amount. The amount will be automatically accounted to your Mileage Account, usually Account # 800

Total Mileage

Total trip mileage: __________ miles X .58 = $___________ ($ to be reimbursed)

Explanation of trip:

Funds In Advance

Under special circumstances, we can issue a payment in advance of the expense being incurred. A common example might be group travel expenses, like food or lodging, when large amounts will be spent and you prefer not to pay out-of-pocket and be reimbursed later. Also, occasionally event vendors require payments/deposits before an official invoice is issued.

1) Please complete the Payee Information and Payment Method sections above.

2) Describe what the requested funds will be used for:

3) Estimate the anticipated costs. How much do you need in advance?

4) Receipts must be submitted within 15 days documenting reasonable ministry use of all funds.

If receipts are not received (up to the amount paid in advance), you will either need to return the unused funds OR we will process it as Contract Labor (aka taxable income to the Payee).

I will provide receipts within 15 days