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UW BUDGET #: ___
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VOUCHER #: ___ PO/REF #: ___
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MAIL TO: ___
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PLEASE RETURN INVOICE COPY WITH PAYMENT AND REFERENCE
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U.W. BUDGET # ___
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AND INVOICE # ___
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ON PAYMENT.
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FOR ELECTRONIC PAYMENTS PLEASE REFERENCE BUDGET # AND INVOICE # IN THE BEGINNING OF PAYMENT DETAIL.
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FINAL/INTERIM: INTERIM
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GRANT/CONT #: ___
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GRANT NAME: ___
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PI NAME: ___
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GRANT PERIOD: ___
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AWARD AMT: ___
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FED TAX ID: 916001537
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TERMS: NET 30 DAYS
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REMIT/MAKE PAYABLE TO: ___
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--------------------------------------------------- Unstructured Table Begin
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BILLING PERIOD: CURRENT CUMULATIVE
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SALARY:
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CONTRACT PERSONAL SERVICES:
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CONTRACT OTHER SERVICES:
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TRAVEL:
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SUPPLIES/MATERIALS:
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EQUIPMENT:
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RETIREMENT/BENEFITS:
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STIPENDS/TUITION:
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DEPT ADMIN OVERHEAD:
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COST TRANSFERS:
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INDIRECT COSTS:
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UNALLOCATED:
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INSTITUTION ALLOCATION:
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TOTAL: $ - $ -
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LESS WITHHOLDING: $ - $ -
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AMOUNT DUE THIS VOUCHER: $ -
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--------------------------------------------------- Unstructured Table End
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CONTACT PERSON: ___
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PHONE: ___
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EMAIL: ___
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MAILING ADDRESS: 3917 University Way NE. Seattle, WA 98105-1 22
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I CERTIFY THAT ALL EXPENDITURES REPORTED (OR PAYMENT REQUESTED ARE FOR APPROPRIATE PURPOSES AND IN ACCORDANCE WITH THE PROVISIONS OF THE APPLICATIONS AND AWARD DOCUMENTS.
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SUW1042
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___ DIRECTOR OF CAMPUS SERVICES, GCA
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Page 1 of 1
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18
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--------------------------------------------------- Unstructured Plain Text Format 1.0.4
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Unum
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GROUP INSURANCE ENROLLMENT FORM
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Unum Life Insurance Company of America
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2211 Congress Street, Portland, ME 04122
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Please print legibly and complete this form in its entirety. Blank fields will cause significant delays in processing.
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Policyholder Name
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______________________
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Policy No.
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______
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Division No.
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____
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Employee Social Security Number
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--------------------------------------------------- Unstructured Redacted Text Begin
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--------------------------------------------------- Unstructured Redacted Text End
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Gender
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M []
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F [x]
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Date of Birth (mm/dd/yyyy)
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02/29/1968
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Hours Worked Per Week
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40
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Employee First Name
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WILLENE
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M.I. M
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Last Name BRONDUM
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Employee Street Address
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1645O E AVE
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City
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FTN HILLS
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State
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AZ
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