Departmental Chargeback

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Departmental Charge back
Charge back Information
Source Department
Contact Person
Department Tracking #
Contact Phone Number
Description
Estimated labor hours
Cost per Hour $
= Total Variable Cost
Equipment Cost
Other Cost
TOTAL COST
Requesting Department Manager
Approved
Approved with conditions*
Denied
Accounting Code
*List Specific Conditions below:
Signature
Date
Comments:
IT Manager Review
Approved with conditions
Denied*
Assigned to
Title
Date Assigned
Priority
*If denied, list reasons for denial
Comments
Completion Date
Requestor's Signature
Please return this form to the IT Department
RECEIPT (please keep this portion for your records)
Charge Description
Date Received