ONE TIME PAYMENT split v2 - University of California, Irvine



INTERCAMPUS ONE-TIME PAYMENT

UNIVERSITY OF CALIFORNIA, IRVINE

| |HOME CAMPUS:       | | |HOST CAMPUS: University of California, Irvine |

| |HOME SCHOOL:       | | |HOST SCHOOL:       |

| |HOME DEPARTMENT:       | | |HOST DEPARTMENT:       |

| EMPLOYEE DATA FROM HOME CAMPUS |COMPENSATION FROM UC IRVINE CAMPUS |

|Employee’s Name:       |One-Time/Honorarium Amount of: $      |

|Employee’s ID Number:       |Event or Service Dates:       To:       |

|Home Campus Appointment Title:       |Temporary Appointment Title:       |

| Title Code:       Percent :       % | Appointment Title Code: 1650 Lecturer - Misc. 3999 Miscellaneous |

|Annual Salary: $      Monthly Rate: $      |Appointment DOS Code: HON (Honorarium) BYA (By Agreement) |

|Basis/Paid Over: 9/9 9/12 11/12 Semester |Account Number to be Charged: __9 -      ______- 2_ |

| |Use ONLY “Non-19900 Funds” Location/Account Fund/Sub Account |

|Current Appointment Dates:       To:       |Account Name to be Charged:       |

|REASON FOR EVENT OR SERVICE AND COMPENSATION |

|(Please Explain the Details of the Event or Service and Compensation. Attach Written Justification for Exceptional Salary) |

|      |

| APPROVALS |

| |

| |

|_______________________________ ____________________________ _____________________________ ________________________________ |

|Irvine Campus Date Irvine Campus Date Irvine Campus Date Home Campus |

|Date |

|Fund Source Authorization Dean’s Authorization Academic Personnel Academic Personnel |

|Prepared By:       Date Prepared:       Information Obtained From:       Telephone:       |

| F O R P A Y R O L L U S E O N L Y |

EMPLOYEE

IDENTIFICATION NUMBER | |

LOC |ACCOUNT FUND/SUB |EMP

REL |APPT

TYPE |DUC |TITLE |DESC

SERV |BY AGREEMENT

AMOUNT | PAY PERIOD END DATE_

MO DY YR | |1 9 |10 |18 |31 |71 |72 |73 |40 43 |44 | 47 53 | 81 | |86 | |

. . . . . . . . . |FT | |

. . . . . . . . . . | | | |

. . . |

. . |

. . . . . . | | | | | CC: After Campus Approval - Employee’s Home Department /Dean’s Office UCI-AP-71

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