REQUEST FOR DISBURSEMENT OR CHECK
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Date
*
Submitted by
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Date Check Needed
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Phone
*
PAY TO THE ORDER OF:
NAME
*
Address
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Total Reimbursement Amount
*
PAYMENT FOR (DESCRIPTION)
*
UPLOAD RECEIPT
*
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Upload (8MB)
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Upload (8MB)
Please note: Except for mileage, all requests for reimbursement must be accompanied by the original receipt for all expenses incurred.
CHARGE TO:
Line Item Name
Line Item Number
Approval
All requests need approval by the appropriate Ministry Department Head
Ministry Department Head, Title
*
OFFICE USE ONLY
Date Paid
CHECK #
Payment Amount
Submit
Description
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