Items 1 - 5 and Approvals section to be completed by all
Enter the date of the request
Enter the name of the unit requesting the rate
Provide a brief description of rate(s)
Enter the Cost Collecter (Cost Center and/or Internal Order numbers)
Select New Rate, Existing Rate, or No Rate Change and complete the appropriate section of the form
Items 6 - 14 to be completed for "New" Rates
Enter the proposed rate (if more than one (1), attach list)
Provide an explanation as to why a new rate is required
Check all that apply:
Check this box if other Penn State University (PSU) departments will be charged the new rate
Check this box if PSU Faculty and/or Staff will be charged the new rate
Check this box if Students will be charged the new rate
Check this box if an External Not-for-Profit Organization will be charged the new rate
Check this box if an External For-Profit Organization will be charged the new rate
Check this box if the General Public will be charged this new rate
Check this box if government entities (includes charges directly to government grants or contracts and flow-through) will be charged the new rate
Enter the name of the building where work will be performed
Enter the room name/number where the work will be performed
Will equipment be used? Check yes or no
If equipment will be used, list the tag numbers of each piece of equipment
Check the appropriate box if rates are based on Actual or Market Rates
NOTE: If rate will be charged to Government or Government Flow-Through, rate must be based on actual costs.
If Market rates are used, attach benchmarking documentation
Check the appropriate location where rate is applicable (only check one box)
University Park (UP)
Commonwealth Campuses
College of Medicine
All locations
Items 15 - 25 to be complete for "Existing" Rates
Enter the previously approved rate(s)
By what percent did the rate change?
Provide an explanation for the increase or decrease
Is this a Finance & Business area rate? Check Yes or No. If yes, the rate must be approved by the Senior Vice President for Finance & Business.
Did the rate(s) change more than 10% since last rate approval? Check yes or no. If the answer to the above two questions are both no, the Financial Officer has authority to approve
Check all that apply:
Check this box if other Penn State University (PSU) departments are charged the existing rate
Check this box if PSU faculty and/or Staff are charged the existing rate
Check this box if Students are charged the existing rate
Check this box if an External Not-for-Profit Organization are charged the existing rate
Check this box if an External For-Profit Organization are charged the existing rate
Check this box if the General Public are charged the existing rate
Check this box if government entities (includes charges directly to government grants or contracts and flow-through) are charged the existing rate
Enter the building name where work is performed
Enter the room number where work is performed
Is equipment be used? Check yes or no
If equipment is used, list the tag number of each piece of equipment
Check the appropriate box if rates are based on Actual or Market Rates
NOTE: If rate will be charged to Government or Government Flow-Through, rate must be based on actual costs.
If Market rates are used, attach benchmarking documentation.
Check the appropriate location where rate is applicable (only check one box)
University Park (UP)
Commonwealth Campuses
College of Medicine
All locations
Approvals Section
The following approvals must be obtained:
The Budget Administrator enters their name
The Budget Administrator must provide either a hand-written signature or provide their digital ID
If the Budget Administrator provides a hand-written signature, enter the date the form was signed, If a digital ID provided, skip this field. The Budget Administrator forwards the form to the Budget Executive
The Budget Executive enters their name
The Budget Executive must provide either a hand-written signature or provide their digital ID
If the Budget Executive provides a hand-written signature, enter the date the form was signed. If a digital ID provided, skip this field. The Budget Executive forwards the form to the Financial Officer
The Financial Officer enters their name
The Financial Officer must provide either a hand-written signature or provide their digital ID
If the Financial Officer provides a hand-written signature, enter the date the form was signed. If a digital ID provided, skip this field. The Financial Officer forwards to Cost Analysis
The Cost Analysis representative must provide either a hand-written signature or provide their digital ID
If the Cost Analysis representative provides a hand-written signature, enter the date the form was signed. If a digital ID provided, skip this field.
If the rate is a Finance & Business rate, the Senior Vice President for Finance & Business enters their name
The Senior Vice President for Finance & Business must provide either a hand-written signature or provide their digital ID
If the Senior Vice President for Finance & Business provides a hand-written signature, enter the date the form was signed. If a digital ID provided, skip this field. The Senior Vice President for Finance & Business sends the form back to Cost Analysis for processing
The Cost Analysis Department completes the final section of the form
