Financial RFR Template

FINANCIAL REQUEST FOR RELEASE (RFR)

Request Identification

Request Number:    Date Submitted:

Requestor / Department

Contact Phone:    Email:

Payee / Beneficiary

Payee Type: Individual Vendor Contractor Other

Payment & Banking Instructions

Total Amount Requested:    Currency:    Payment Due Date:

Preferred Payment Method: ACH Wire Check Other

Itemized Breakdown (if applicable)

Subtotal:    Tax:    Shipping / Fees:    Total:

Supporting Documentation

Attached Documents: Invoice Purchase Order Contract Expense Report Other   Specify:

Certifications & Representations

By submitting this Request for Release of Funds, the Requestor certifies that the amounts requested are true and correct to the best of their knowledge, that goods or services have been provided or will be provided in accordance with contract terms, and that funds are available and properly charged to the budget or project code indicated. The Requestor further certifies compliance with applicable procurement and internal control policies and acknowledges that any disbursement made in reliance on incorrect information may be subject to recovery.

Requestor attests that payment to the payee will not result in a violation of applicable tax withholding obligations; Requestor authorizes the finance office to withhold taxes or to request additional documentation if required by law or policy.

Certification of Availability of Funds: Budget Code has sufficient available balance to cover the requested amount. Authorized approver initials:

Routing & Internal Review

Department Head Review Date:    Comments:

Finance Review Date:    Verified Budget Availability: Yes No

Processing & Payment Terms

Standard payment processing applies. Payments are subject to verification, withholding for taxes or liens, and may be delayed if supporting documents are incomplete. Late payment requests may incur processing fees in accordance with policy. The finance office may require additional internal approvals for amounts above delegated thresholds.

For Finance Use Only

Date Processed:    Processed By:    Payment Method Used: ACH Check Wire

Transaction Reference / Check No.:    Posted to Ledger: Yes No

Terms, Liability & Audit

The Requestor acknowledges that payment will be made only in accordance with contract terms, statutory obligations, and internal policy. The organization reserves the right to recover any overpayment, improper payment, or payments made in error, including amounts paid to third parties. Requestor agrees to retain and provide, upon request, all supporting documentation necessary for audit and compliance review for the period required by policy and law.

Limitation of Liability: Except to the extent required by applicable law, the organization’s liability for payment errors is limited to correction of the error and does not include consequential or incidental damages. Requestor certifies that the payee is not debarred or suspended from receiving public funds where applicable.

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