DISBURSEMENT VOUCHER PAYEE CERTIFICATION

I hereby certify that the information relating to FIS (TP) Document Number _________________ requesting payment for expenses is just and correct. I certify that all charges and/or reimbursements pertain to Indiana University business, that the amount is legally due after allowing all just credits and that no part of the same has previously been paid or will be paid by another source.

Amount of payment: $ _________________________
__________________________________ Payee Signature (original signature required)	__________ Date
____________________________________________ Account Manager Signature