Chargeback Entry Request Form

Instructions: Enter information pertaining to the chargeback entry you would like created. Chargebacks are requested by the department providing goods or services to another department(s) on campus. Some examples of a chargeback might include copier usage, RHA planners, etc. This information will be sent to Jean Cupernall in Financial Services. Detailed information on Chargebacks is included in the Journal Entries & Chargebacks user guide on the Financial Services web site.

Use the Journal Entry Request Form for transactions involving moving "Actuals" (expenses paid or adjustments applied to an account).

Do not use this form for Budget Transfers, instead, contact Noelle Bartolis in the budget office for requests involving 01 fund accounts only.

* Indicates required field.


* Requester Name
* Requester Email
* Phone
* Fiscal Year
* Account Number
(always use Subcode 95XX)








Please do not skip lines when entering chargeback information below. Thank you.


* Account Number (Debit-To)

* Description of Transaction (Include Dates of Service)









Incomplete and/or incorrect entries will be returned to requestor for correction.

Requesters will receive confirmation once this entry has been made. Please forward the confirmation to others as needed.











this page maintained by Jo Anne Rosato:: last updated on December 23, 2013