INVOICE DISTRIBUTION FORM

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- For Accounts Payable Use Only Date:

SOUTHERN ILLINOIS UNIVERSITY

Department/Contact Information: Dept. Name:

Entered By:
Phone No:

Contact Name:

Mail Code:

Please complete the following information, attach to the invoice and forward to Accounts Payable, Mail Code 6818. If you have any questions, please call Accounts Payable at 536-2351.
General Instructions:
1. Each invoice must have the Account Distribution section completed.
2. The Fiscal Officer must sign for each unique Budget Purpose in ink (other than black).
3. The original form and invoice must be returned to Accounts Payable.
4. Complete a second form if the expense is to be split more than five ways.
5. Complete a Seller's Certification section at the bottom if necessary to obtain payee's signature.
Supplier
Information:

Name:

AIS Supplier No.:

Michael Fralaide

Address Ln 1: 460 Collen Dr.

Supplier Site Name:

Address Ln 2:

Is the Supplier's owner, major officer or member of their

immediate family a State employee?

City: Lombard

State:
Invoice Date:

Invoice Number:

Yes

Yes

No

Conflict of Interest
Procedures

335844241

Payment To: Graduate Assistant

Pay Alone

(If no, the payment must be processed on a Contractual Service Voucher.)

Send Attachments with Check

Ending/Received:

If "Yes", please refer to:

No

TIN or SSN:

PO Type:

Is the payment to or on behalf of a U.S. Citizen or Permanent Resident?

Dates of Service: Beginning/Ordered:

Zip Code: 60148

Dollar Amount of Invoice:

Release No.:

PO Number:

IL

Special Handling

Description/Note
to
Accounts Payable:
Additional Departmental Accounts Payable Forms

Invoice Account Information

Date

Fiscal Officer Name

(Typed)

Fiscal Officer Signature

Budget Purpose
(or Alias)

Dept
Act 1

Account Distribution
Dept
Func Nat Act Obj
Act 2

FY

SOF (Proc
Serv Use Only)

PO Line
Number

Dollar Amount

Total

SELLER'S CERTIFICATION

I hereby certify that the Goods, Merchandise, Ware, or Services shipped or performed in accordance with this invoice have met all of the required standards set forth in the Purchasing Contract and are proper
charges against the State of Illinois or Board of Trustees of Southern Illinois University and that payment has not been received.
Signature
ACP 0302
11/14

Michael Fralaide

Digitally signed by Michael Fralaide

DN: cn=Michael Fralaide, o=Southern Illinois University Carbondale, ou, email=MichaelFralaide@siu.edu, c=US
Date: 2015.04.16 10:28:14 -05'00'

SUBMIT COMPLETED FORM, WITH INVOICE, TO ACCOUNTS PAYABLE, MC 6818

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