Complete the top portion of this form and return it to:

Office of the State Comptroller
Bureau of State Expenditures
Knowledge Management Unit
Albany, NY 12236
FAX: (518) 473-3380

Quick Pay Refund Request Form

Agency Name: _______________________________________________________________

Agency Code: _______________________________________________________________

Types of Refunds
Issued by Agency: ____________________________________________________________

Contact Name
and Title : ___________________________________________________________________

Telephone No.
with Area Code: ______________________________________________________________

The following information will be required at a later time.

A. Name and operator ID's of persons to certify:

NOTE: These certifiers must be authorized to sign vouchers, in accordance with Section 110 of the State Finance Law, and must be on file with OSC Knowledge Management Team.





B. Names and operator ID's of persons to enter Quick Pay Refund Vouchers.




C. Description of types of refunds issued by the Agency.




D. For each type of refund issued, list the coding (dept., cost center, var., yr., object) used on the original Report of Moneys Received or Journal Voucher.





cc: Bureau of Accounts