Make check payable to:
Name___________________________________________
Address_________________________________________
Phone/Contact____________________________________
Mail check to:
Name___________________________________________
Address_________________________________________
Date Vendor Purpose of Receipt Amount
Expense
______ _________________ _________________ ______ ____________
______ _________________ _________________ ______ ____________
______ _________________ _________________ ______ ____________
______ _________________ _________________ ______ ____________
______ _________________ _________________ ______ ____________
Check Total ____________ (Sales Tax will not be reimbursed)
Submitted by/Committee__________________________________
__________________________________________________________________________
For Treasurer’s use:
Date________ Check #________ Amount______
Budget Line________________