Note: Separate forms should be submitted for revenues versus expenditure reductions.
To Central Deposit, Division of Business Services: The division/office above has received the sum and number of remittances below. The payer information is indicated further below.
After you complete and submit this form (see Submit button below), a copy of the form will be emailed to you. Print the emailed form and bring it with the remittances to the Accounting Office, Payroll Section.
TO BE COMPLETED BY ACCOUNTING: