Payment Request Form

Note: An Incident Report must be completed beforehand! Payment will not be processed otherwise.

(IR form: https://infraservices.tfaforms.net/7)

Date Incident Report Submitted:

Type of Claim for Payment Request

Requester Information

Requester Name

Requester Email (read only)

Requester Phone Number

Requester's Manager Name

Manager Email (read only)

Manager Phone Number

Home Office

Division

Damage Ticket Number (if applicable)

Claim is related to:

In-HouseSubcontractor

In-House Employee Name

Subcontractor Details

Subcontractor Company Name (EXACT legal name required)

Subcontractor not found?

True

Subcontractor Name Input

Has Subcontractor been notified of pending back charge?

YesNo

! - This Request will not be accepted without a completed Subcontractor Back Charge Form

Subcontractor Point of Contact (Name)

Subcontractor Point of Contact (Email Address)

Subcontractor Point of Contact (Phone Number)

Check Request Amount

Comments

Attach: Incident Report

Attach: Check Request Form

Attach: PO Request Form

Attach: Subcontractor Back Charge Form *

Attach: Invoice (if applicable)

Address

Account ID

Requester Contact ID

Manager Contact ID

In-house Employee Contact ID

Subcontractor ID