52-22
REQUEST FOR COVERT PAYMENT OTHER THAN CASH
FD/O&L Log No. _______________
TO: Finance Division, Room [redacted]
FROM: TSD/FS 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) [redacted], Ph. D. $500.00
Name of Payee (True)
Status (e.g., CA; SA; CE; Integree)
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. X Bank Cashier Check (circle city below)
e. ______ Deposit to Payee’s Bank Account (complete par. 3, below)
CITY DESIRED [redacted]
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, Ext. [redacted]
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. [redacted]
(A) [redacted]
Requesting Officer, Ext. 2841
* Notify for delivery of check
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FOR USE BY FINANCE DIVISION ONLY
Payroll Number: ___________________________ Roll Number: ___________________________
Method of Payment: ___________________________ City: ___________________________
[redacted]