REQUEST FOR COVERT PAYMENT OTHER THAN CASH
FD/O&L Log No. ___
TO : Finance Division, Room
FROM: T6D/EB Division
It is requested that payment authorized on documents reflecting obligation reference number (or other divisional ref. no.) 2125-1390-3902 be made in the following manner:
1. Payment to: (C) Name of Payee (True) Status (e.g., CA; SA; CE; Integree) $ 500.00
By:
a. ___ U. S. Treasury Check (for official cover only)
b. ___ Covert Check (individual type - circle city below)
c. Covert Check (commercial type = circle city below)
d. Bank Cashier Check (circle city below)
e. ___ Deposit to Payee's Bank Account (complete par. 3, below)
CITY DESIRED
2. Payment by other means:
A. If payment is to be originated by foreign bank - specify requirements: ___
B. Payment by other means and/or special instructions (foreign and domestic bank drafts, cover story, travelers check, letter of credit, etc.) specify: ___
C. Payment by either 2 A or B above, should be discussed with the Monetary Branch Banking Officer, Ex
3. Banking instructions (for use by Requesting Officer if instructions are not on file in Finance Division):
Account Name: ___
Bank and Bank Address: ___
4. For further information regarding this request please contact: TSD/FASS
Ext.
(A)
Requesting Officer, Ext. 2841
* Notify for delivery of check
FOR USE BY FINANCE DIVISION ONLY
Payroll Number:___ Roll Number:___
Method of Payment:___ City:___