PAYMENT REQUEST FORM

For use where payment is to be made to non-staff individuals or organisations for reimbursements, donations, prizes, refunds etc.
Payments to staff and students must be processed through the Travel and Expense Management System (Concur)

Note: For reimbursement Tax Invoice/Receipts and/or documentation MUST be attached

Payee Details:
Payee Name: School/Business Unit:
Postal Address: Approver Name:
E-Mail Address:
Phone Number:

Bank Account Details

Domestic Claims: International Claims:
BSB: Bank Name:
Account Number: Bank Address:
Account Name: Account name:
Account number:
Sort code / ABA routing number / Swift Code:
Claim Details
Amount incl Amount excl
Item Cost Centre Project Account Campus Entity Type GST
GST GST
1 $ - $ -
2 $ - $ -
3 $ - $ -
$ - $ - $ -
CLAIMANT

Claimant Signature:…………………………………………………. Date :………………………………………………………………..

Instructions
1 Complete payee details
2 Complete claim details - one line per item. Delete GST calculation if GST free
3 Print page above
4 Sign claimant declaration
5 Scan this page and supporting documentation/receipts as one document to 'invoices@westernsydney.edu.au'. Scan must be in PDF format

Your claim will be imported into Basware then forwarded to the relevant School/Business Unit for approval online