Date
Note: Initiator cannot be the same person as the Payee
Name Department
LU E-mail @liberty.edu Phone #
Payee/Vendor Information
Employee ID # Date Check Needed
Payee/Employee Name:
Additional Documentation Attached
1
2
3
4
$
$
$
Purpose/Description
$
Payroll Index Code Account / Commodity Amount
Request for HR Disbursement
Initiator Information
5
Total Check Amount
Approvals
(Print) (Sign) Date
(Print) (Sign) Date
(Print) (Sign) Date
$
$
(Print) Date
(Sign)
Dept Supervisor/Chair
Dean/Division Leader
Vice Provost (Academics)
Provost (Academics only)
VP for Human Resources
(Print)_________________________________(Sign)_____________________
Date _______________
Clear Form
0.00