If primary or secondary country is one of the following OFAC embargoed countries: Myanmar (Burma),

Sudan, Syria, Iran, Cuba,Crimean region of Ukraine, or North Korea, forward request to Director, Corporate
Contracts and Export Control Licensing, via email to donald.deyo@yale.edu for approval prior to
completing form or submitting request.

Form 3401 FR.02 Check Request Not to be used for employee reimbursement Check Request Date:
Payee Name (Individual or Vendor Legal Name): Vendor #:
Trade Name ("doing business as"): (if applicable) Click here for TCN CR (TCN) #:
Payment Mailing Address: Permanent Home Address: Special Handling: Taxpayer ID(SSN/ ITIN /EIN):
Pay Alone
New Vendor? Vendor Change?
OISS
Pickup-2 Whitney Treas Svcs, Email: @yale.edu
Pickup-Med School Treas Svcs, Email: @yale.edu
Vendor Type: Non-Employee Business Purpose: Travel Dates; From: To:
Vendor - Provider of: goods services goods/services List of Attendees or Group:
If "services", type of services: International Use Only http://yalebiz.yale.edu/content/international-activities
Expense Report Type: (For Intl. Complete Info to right)
Primary Country of Activity: Secondary Country of Activity:
Domestic International Primary Activity: (enter, manually, (1) for Primary Cntry, (2) for Secondary Cntry)
Type of Organization: (a box must be selected) Fundraising Academic Collaborations Seminars & Conferences (attending)
Grantmaking Cultural Exchange Seminars and Conferences(speaking and attending)
Individual - US citizen or US permanent resident ("green card")
Investments Instruction/Teaching Student Recruitment
Individual - Non-US citizen and non-US permanent resident Unrelated Trade/Business Other Mission Related Activities Study Abroad/Educational Pgrms
Sole Proprietorship Alumni Relations Research (inc.field work) Training/Clinical Practice
Partnership - US If Payee is not a US Citizen/Permanent Resident:
Corporation - US (includes 501(c)3 non-profit corporation) Country of Permanent Residence:
Government Agency - US Visa type J1 F1 B1 B2 WB WT Other
Non-US: Corporation Partnership Govt. Agency Refer to International Payees Web Site for documentation needed. http://tax.yale.edu/intl-payment-requests
SECTION I: Travel Reimbursement - Non-employees only. *See Instructions below for expenditure type codes.
Description Project (7) Task (8) Award (6) ExpType (6) Org (6) Total Amount

SECTION II: Honoraria, Royalties, Commissions, Prizes, Fellowships, Awards, Study Subject Payments. If subject to CT A&E Tax, attach Form CT-590 if applicable.

SECTION III: Other Payments. Goods up to $500; direct payment of license fees, conference fees, subscriptions, reprints, memberships, etc.

Initiator Name & NetID: (type or print)

Preparer Name: (type or print) Signature/Date: Phone: Dept: Total Amount: 0.00
E-mail: TEAR#: Advance Amount:
Authorizer Name: (type or print) Signature/Date:
AUTHORIZER: I certify that I have reviewed claims associated with this payment request, have
Amt Due Payee: 0.00
found them in compliance with both Yale policies and procedures and policies of any sponsoring
agencies funding these activities, and hereby authorize payment and hereby attest to the truth of
the statement here within.
Refund To Yale: 0.00

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Instructions- 3401 FR.02 Check Request
LINKS to References: (a) Policy 3410 CT Income Tax Withholding for Nonresident Athletes and Entertainers
(c) Policy 3302 Business Meals and Entertainment (d) Policy 3401 General Payment
Use the Check Request (CR) form to request payment for:
travel or other University business expense reimbursement for non-employees;
professional services, honoraria, prizes and aw ards, fellow ships or study subject
payments;
Or to request a vendor payment for a transaction w ithout a supporting invoice;
w hen a Pcard is not an option. Examples: licensing agencies, conference
sponsors or journal publishers.
Check Requests for reimbursement of non-employee travel and other expenses should
be filed w ithin ten (10) business days after the date of completion of the trip or the date
on w hich the expenses w ere incurred. If a postdoctoral fellow or student has an
outstanding advance, enter the outstanding amount and TEAR number in the spaces
provided. Attach a check payable to Yale University for any refund due Yale.
Complete the Form :
Payee Name and Paym ent Mailing Address: The check w ill be mailed to this address
unless vendor paid by ACH or Pickup or OISS under Special Handling is checked.
Payees Residence, Dom icile or Permanent Place of Abode: Payees residence for
Income Tax purposes. Contact the University Tax Department (2-5530) if you need
assistance. Enter only if different from Payment Mailing Address.
CR Date and CR#: Today's date and TCN (i.e., CR1234567), required for this form.
Taxpayer ID: Please indicate Payee's Social Security number, International Tax ID
number if foreign, or Employee Identification Number if a vendor. SSNs should only be
present on CR From being sent to VCU. If being sent to AP, any SSN info must be
scanned and attached in a separate pdf attached to CR email and not appear on the
CR form.
Vendor Number: Required for this form (see Procurement Inquiry)
If payee is not in vendor database, check New vendor. If data for an existing
vendor has changed, enter vendor number and also check Change vendor data.
Separate Vendor Setup Request form is preferred.
Vendor Type: Check the box that show s the payee's vendor type:
Non-Em ployee: Individuals such as visitors to the University w ho are not
University employees and w ho receive honoraria and/or travel reimbursements
(not individuals w ho routinely sell goods or services see Vendor above).
Petty Cash Custodian: Employees w ho are authorized custodians of specialized
petty cash funds. They are set up in the vendor database w ith "PCC" follow ing
their name.
College/University: Colleges or universities that provide goods or services to
Yale.
Vendor (s/b rarely paid by CR): Corporations, partnerships and individuals that
routinely provide goods and services. Also indicate w hether the vendor provides
goods, services, or both. If vendor provides services, enter type of service.
Type of Organization: Check the box that show s the payee's organization type. A box
must be selected otherw ise processing of the transaction w ill be delayed. If unsure,
contact the payee
Air/Rail Lodging Car Rental Ground Transportation Per Diem/Actual Meal
Domestic 871010 871020 871030 871040
International 872010 872020 872030 872040
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DO NOT USE THIS FORM FOR UNIVERSITY EMPLOYEES
(b) Policy 3301 Traveling on University Business
(e) Controller's Fact Sheet
Special Handling: If special handling is required, check the appropriate box. If you
require other special handling on a Rush basis, please send CR to
sharedservices@yale.edu and indicate Rush CR and CR #.
Travel Dates: From and To dates if travel expenses are involved.
Business Purpose/Explanation of Business Meals/List of Attendees: Enter a
complete business purpose of expenses. For business meals & entertainment, also list
the attendees or a description of the group (if greater than 10) and state their business
relationship to Yale. Attach separate sheet if needed.
If Payee is not a US citizen or US permanent resident: This information is required.
Ref er to Check Request for International Payees w eb site for required documents. Link
is on CR form. For assistance, contact International Tax Office at 432-5597.
Section I: Itemize non-employee travel expenses to support reimbursement request.
Attach receipts as required by Policy 3301
Lodging: Enter hotel name, nightly rate and number of nights.
Personal meals: Enter actual expenses or federal per diem meals and incidental
expenses (M&IE) rate for the location, enter number of days of trip (prorate partial
days) and multiply to get total. Itemize alcoholic beverages separately and charge to
expenditure type 873000
Mileage: Enter number of miles and multiply by current mileage rate.
Section II: Itemize payments to non-employees for honoraria, prizes, aw ards or
fellow ships, study subject payments. Attach supporting documentation.
Subject to CT Athlete and Entertainer Tax? If payee is an athlete or entertainer,
including guest speaker, w ho is not a Connecticut resident, check Yes. State of CT
requires Yale to w ithhold state tax from the payment unless payee qualifies for
reduction in w ithholding or exemption from w ithholding. Contact Tax dept. for help at
432-5530.
Section III: Use this section to request payments for a transaction w ithout a
supporting invoice; w hen a credit card is not an option.
Initiator: Print the name & NetID of the individual w ho requested that the goods/or
services be ordered and w ho determines that the costs are reasonable, allow able and
allocable to the source of funds.
Preparer: Print the name and include the signature of the individual w ho prepared the
check request form on direction from the Initiator. Note: can be the same as the
Initiator.
Authorization: A department administrator w ith the responsibility (via START) to
approve and commit university funds must review and sign the form. By signing, the
authorizer accepts the authorizer certification printed on the form. Exceptions to
University policy require additional authorization by a Corporation officer or designee.
Submit the Form : Scan original receipts and required supporting documentation as
pdf file and submit to yss.checkrequests@yale.edu. One CR per email. SSN
information must be sent in separate pdf file and attached to CR email. Call 432-5394
or email sharedservices@yale.edu if help required.
Miscellaneous Alcohol & Entertainment 873000
871050 871060 Business Meals 874000
872050 872060 Conference Fees 875000
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