Payment Verification Form

Associated Files

Details

All individuals and businesses that are due reimbursements/payments from a state agency will receive a letter and Payment Verification Form to complete and return to the Office of the State Controller (OSC). These payments could be related to performing a service, providing goods or may be a one-time reimbursement for an overpayment or other transaction.

You may receive a Payment Verification Form if you perform any of the following services:

  • Read to the blind
  • Interpret for the deaf
  • Consult for a state agency
  • Serve as a contractor for a state agency
  • Coach
  • Speak at a conference or seminar
  • Provide legal or other counsel

This form is sent as a courtesy so that the recipient (individual or business) can verify and ensure all of the printed information on the form is correct and up to date. For example, it is important that the Tax Identification Number (social security number or federal tax identification number), vendor name and address information are correct. Additionally, it is helpful that other general information (Individual and Business Characteristics parts I and II and phone/contact data) on the form is completed for informational purposes.

Completing and returning this form does not affect your Social Security payments, tax refunds, welfare checks, AFDC payments or other entitlement checks. If you choose not to complete this form, another one will automatically be mailed to you in approximately two months.

The links below may be helpful when completing this form. In fact, the Field Descriptions link will walk you through each field on the form and explain what information is needed in each field. If you should have additional questions, please contact the OSC Support Services Center at 919-707-0795.

Payment Verification Form Instructions

 

1.

Federal Tax ID Number/Social Security Number for Individuals (9 digits):  Please check to make sure this information is correct.  If it is incorrect, please write in the correct information.

2.

Name of Vendor or Individual:  Please check to make sure this information is correct.  If it is incorrect, please write in the correct information.

3.

If Sole Proprietorship, owner's name:  If the business is a sole proprietorship, please print the owner's name.

4.

Address for Ordering Goods and/or Services:  If applicable, please verify or print the correct mailing address for state agencies to use to send purchase orders when ordering goods or services. If you have registered using E-Procurement @ Your Service, this section will not need to be completed.  

5.

County Name:  The county where the address for ordering goods and/or services is located.

6.

Fax Number, Toll-Free Phone number, Area Code & Phone Number, Email Address, and Contact Name:  Please complete with the appropriate information.

7.

Remittance Address:  Please verify or print the correct mailing address where state agencies are to send payments.

8.

County Name:  The county where the remittance address is located.

9.

Fax Number, Toll-Free Phone number, Area Code & Phone Number, Email Address, and Contact Name:  Please complete with the appropriate information.

10.

Type of Business Structure: Please check each characteristic that applies to you or your business.

11.

Does your business provide:  Please check the option that most closely represents your business.  Individuals do not need to answer this question.

12.

Does your business provide medical services?:  Please check yes or no.  Individuals do not need to answer this question.

13.

Form Completed By:  Please sign and date the form at the bottom and mail it to the address listed at the top of the form, email it to OSC.Support.Services@osc.nc.gov or fax it to (919) 981-5561.

 

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