PAYMENT REQUEST
Michigan Department of Health and Human Services
DOCUMENT INFORMATION (For MDHHS Accounting Use Only)
Code	Unit	ID	Pre-Audit By	Entered By	Approved By
DOCUMENT INFORMATION
Case Name
HEADER INFORMATION
Document Description
COVID-19 Family Needs Purchase
Extended Description (if applicable)
Print/Type Name of Case Worker	Signature of Case Worker	Date
Print//Type Name of Supervisor	Signature of Supervisor	Date
VENDOR INFORMATION
Vendor/Customer Code	Vendor/Customer Name	Address Code
Vendor/Customer Address Line 1	Vendor/Customer Address Line 2
City	State	Zip Code	Single Payment	Central Office Print
Yes	No	Yes	No
COMMODITY INFORMATION
Commodity	CS-138
ACCOUNTING INFORMATION
Invoice Number	Check Description

BFY	Accounting Template	Unit	Dept. Object	Dept. Revenue	Line Amount
20	491XX1302
0.00

Email Contact
Print/Type Name of MDHHS Employee	Signature of MDHHS Employee	Date
Print/Type Name of MDHHS PAL	Signature of MDHHS PAL	Date

Instructions for Completion of the MDHHS-5602

Incomplete or improperly completed forms may be returned to the preparer for completion. This form is to be completed internally by an employee of the State of Michigan MDHHS. Authorized signer is stating they have reviewed entire document and approve. No change may be made once this has been signed.

DOCUMENT INFORMATION – To be completed by the preparer (if client related).

Case Name: Case name from the appropriate system (i.e., Bridges).

HEADER INFORMATION – To be completed by the preparer.

Document Description: Reason for the payment request.

Extended Description (if applicable): Additional information needed for the payment request.

Name/Signature of Case Worker – applicable only if client-based payment

Name/Signature of Supervisor – applicable only if client-based payment

VENDOR INFORMATION – To be completed by the preparer (all information obtained from SIGMA VCUST).

Vendor/Customer Code: SIGMA vendor number used to make payment (this is not a FEIN)

Vendor/Customer Name: Legal name of vendor where payment should be sent.*

Address Code: Number associated with the address where the payment is to be sent. *

Vendor/Customer Address Line 1: Address where the payment is to be sent.*

Vendor/Customer/Grantee Address Line 2: Additional information regarding the address. *

City: City where the payment is to be sent. *

State: State where the payment is to be sent. *

Zip Code: Zip Code where the payment is to be sent.*

*Note: Address must match remit to address on documentation attached.

Single Payment (Y/N): If this payment needs to be paid as standalone to the vendor mark yes. This payment will not be consolidated with other payments disbursed on the same day to the vendor.

Central Office Print (Y/N): Payment request to produce check printed in central office and distributed to requestor.

COMMODITY INFORMATION – To be completed by the preparer (if applicable).

Commodity Code: May be found in SIGMA Commodity Table (COMM).

CS-138: May be found in SIGMA CS-138 table.

ACCOUNTING INFORMATION – To be completed by the preparer.

Invoice Number: Number used to identify payment to the vendor (if none, leave blank).

Check Description: Information to be printed on the remittance advice to allow vendor to identify.

BFY: Budget Fiscal Year to be used on payment.

Accounting Template: Enter code that needs to be used to allocate the funds properly for payment

Unit: Identifies the MDHHS area charged for the expenditure.

Dept Object: Leave this blank – completed by central office Accounts Payable.

Dept Revenue: Coding used on revenue refunds.

Line Amount: Enter for each amount distributed between accounting templates

Contact email: Enter who should be contacted for questions from accounting.

Name of MDHHS Employee: Individual preparing the document (must print and sign).

MDHHS PAL: Person Authorized by MDHHS to sign for that amount and location of services -final approval for payment to be made (must print and sign).

Questions regarding this form can be emailed to invoicemdhhs@michigan.gov.