Check Authorization Form

Purpose: This form serves as an internal control mechanism requiring dual authorization before check release. All fields marked with * are mandatory. Check details will be completed after authorization.

PAYMENT REQUEST INFORMATION

Request Number/ID

Request Date *

Requested Payment Method

Requested Payment Date

VENDOR/PAYEE INFORMATION

Vendor/Payee Name *

Vendor ID/Account Number

Vendor Address

Contact Person

Contact Phone/Email

INVOICE DETAILS

Instructions: List all invoices being paid with this check. Add multiple rows if paying multiple invoices.

Invoice Number *	Invoice Date *	Due Date	Invoice Amount *	Description *	G/L Code

Subtotal: $0.00

Less: Discount/Credit (if any):

Add: Late Fees/Interest (if any):

TOTAL CHECK AMOUNT: $0.00

PAYMENT JUSTIFICATION & DOCUMENTATION

Business Purpose/Reason for Payment *

Supporting Documents Attached

Original Invoice(s) Purchase Order Receiving Report/Delivery Receipt Contract/Agreement Other:

Budget Code/Department

Budget Approval

AUTHORIZATION & APPROVAL (3-WAY CONTROL)

Internal Control Requirement: This form requires three separate signatures - one preparer and two independent reviewers/approvers. No single person should have authority to prepare AND authorize payment release.

PREPARED BY (Administrator)

Name *

Title/Position

Date

Signature

✓ Verified invoice accuracy
✓ Confirmed documentation

REVIEWED & APPROVED BY #1

Name *

Title/Position

Date

Signature

✓ Budget verification
✓ Business purpose approved

REVIEWED & APPROVED BY #2

Name *

Title/Position

Date

Signature

✓ Final authorization
✓ Check release approved

✍️ CHECK DETAILS (To be completed AFTER authorization)

Note: This section should be filled out by the check preparer after obtaining all required authorizations.

Check Number

Check Date

Bank Account Used

Check Prepared By

Check Released By

Release Date

Delivery Method

Notes/Special Instructions

🔒 INTERNAL CONTROL PROCEDURES

Segregation of Duties: The preparer cannot be one of the approvers. At least two independent reviewers must authorize payment.
Documentation Requirements: All payments must be supported by original invoices and supporting documentation attached to this form.
Dual Authorization: Both reviewer signatures are required before check release. Verbal approvals are not acceptable.
Budget Verification: Reviewer #1 must confirm adequate budget availability before approval.
Authority Limits: Payments exceeding $10,000 require CFO/Controller signature as Reviewer #2.
Retention: This form and all supporting documents must be retained for 7 years per company policy.
Review Frequency: All check authorization forms are subject to quarterly internal audit review.

CHECK AUTHORIZATION FORM

🔒 INTERNAL CONTROL PROCEDURES