[name of project/grant] Attachment V

[name of department]

Texas State University

Acknowledgement of Receipt of Cash or Cash Equivalent

By signing this form I am acknowledging that I received cash or a gift card in the value of ___________from ______________________________ as compensation for participation in research.

By signing this form and accepting this compensation, I verify that:

a. I am not an employee of Texas State University.

b. I am a U.S. Citizen or Permanent Resident.

I also understand and acknowledge that should I receive a total of $600 in incentive pay for participating in other research projects offered through Texas State it will be reported to the Internal Revenue Service and a 1099 form will be issued. My mailing address for Texas State to send me a W-9 in the event that my total incentive payments within a calendar year is:

Mailing Address:

_____________________________________ __________________________

Printed Name Last 4 digits of SSN *

_____________________________________ __________________________

Signature Date

As a representative of this study, I am acknowledging that I distributed _______________ to the above named participant.

_____________________________________ __________________________

Signature of Investigator Date

_____________________________________ __________________________

Principal Investigator Date

*A unique number identifier will be accepted if no social security number is available.