Direct Payment Request

This form is to be used when requesting both Direct Payments and Payments to Individuals. Please be advised that direct payments are not to be used to pay UW Students, UW Employees, or Refunds.

Please note that this request will be rejected if you are requesting a Direct Payment greater than $5,000. Please complete a purchase requisition or use the Non-Conforming PO form in ShopUW+.

Please contact BOP at fpmbop@fpm.wisc.edu if you need additional information.

If the request is for a supplier not already set up in ShopUW+ you will be required to obtain a W9 from the supplier.

Contact Information

Name*

Enter your first and last name.

First Last

Email*

Enter your email address.

Phone Number*

Enter your phone number, including area code.

Payee Information

Name of Supplier*

Enter the complete name of the supplier.

Supplier Remit-to Address*

Enter the address where the check should be sent.

Street Address Address Line 2 City State ZIP Code

Purpose of payment*

Example: bulk mail permit fee, etc.

Payment reason*

Describe why the University is making this payment (i.e., the full business purpose of the payment). Example: replenish the permit fee for bulk mail services.

Payment amount*

Enter the amount of this direct payment request.

Invoice number

If you do not have an invoice, leave this field blank.

Is this individual an employee or student of UW-Madison

Yes
No

Funding Information

For help on funding strings, please visit Purchasing.

Note: Each funding string must have the following components:

Department (6 digits)
Fund (3 digits)
Program (1 digit)
Account Code (4 digits)
Project (7 characters, alphanumeric)
Class (4 digits)

Funding String*

Enter one or more funding strings for this direct payment request. If you enter more than one funding string, define an allocation percentage for each row (totaling 100).

Department	Fund	Program	Account Code	Project	Class	Percentage

Attachments*

Attach all of the required documentation for this direct payment request.

Drop files here or

Max. file size: 24 MB.

Note: This form is for FP&M internal use only.

Contact Information

Payee Information

Funding Information