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PAYMENT AUTHORIZATION/REQUEST FOR REIMBURSEMENT

PAYMENT AUTHORIZATION/REQUEST FOR REIMBURSEMENT . ATTACH ALL RECEIPTS TO THIS EXPENSE STATEMENT . Name of Payee PTA Position Address City/Zip Telephone ( ) Email . Expenditure was for: List Expenditures: $ $ $ $ TOTAL EXPENSE $ Total Amount Claimed From Above $ Minus Advance Received $ Reimbursement Claimed $

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WORKERS’ COMPENSATION ANNUAL PAYROLL …

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