FOR FINANCIAL AID PROCESSING ONLY

Does item type exist for this payment?

☐ Yes, use item type _____________________ ☐ No, create item type

Student Prize/Award & Undergraduate Stipend Request

REQUEST TYPE: ☐ New ☐ Revision

QUALIFYING QUESTIONS Answer the following to ensure correct routing and processing of this form. Please choose a request type. ☐ Prize/Award ☐ Undergraduate Stipend

Is the payment to a US Citizen or Permanent Resident?☐ Yes ☐ No

If no, gross up?☐ Yes ☐ No

For undergraduate stipend requests, answer the following questions. Is the student working set hours? ☐ Yes ☐ No

Is the student receiving an hourly or standard wage? ☐ Yes ☐ No

Is the student’s activity directed by a supervisor?☐ Yes ☐ No

PAYMENT INFORMATION Attach additional explanation sheet(s) describing the purpose of this request with this form.

Amount Per Payment ____________________

Number of Payments ____________________

First Payment Month ____________________

Last Payment Month ____________________

___________________________

___________________________

___________________________

Award Intended Term

Dept. Contact Name

Dept. Contact Phone

Name of Award

This award is funded by

PAYEE INFORMATION Full Name _____________________________________ Student Type __________________ EMPLID OR VUnetID __________________

AUTHORIZATIONBy signing below, I certify that I have reviewed and approved the above payment per Vanderbilt University policies.

Financial Unit Manager Name Signature Date

Return completed form to osfa@vanderbilt.edu orOffice of Student Financial Aid and Scholarships

2309 West End Avenue, Nashville, TN 37203

Business Unit Manager Name Signature Date

Values above $10,000 require additional approval from the Business Unit Manager.

Entity3 digits

Net Class Asset 2 digits

Financial Unit 5 digits

Account Program3 digits

Activity 3 digits

Amount

Total Amount

Total Taxes Withheld

Net Amount

ProjectUp to 10 digits

OrganizationUp to 10 digits

Expenditure Type Task Up to 10 digits

Amount

Total Amount

Total Taxes Withheld

Net Amount