REIMBURSEMENT/CHECK REQUEST FORM

1 ATTACHMENT F REIMBURSEMENT/CHECK REQUEST form NAME: DATE: MINISTRY: (RECEIPTS MUST BE DATED WITHIN 10 DAYS FROM ITEM PURCHASE IN ORDER TO RECEIVE reimbursement ) reimbursement REQUEST a) Has this REQUEST been approved and signed by your Elder? Yes _____ No b) Do you have the necessary receipts proving purchase? Yes _____ No c) Please explain the reason for this purchase: d) check should be made payable to: Amt. Due: e) check # given: f) Date check was written: g) check released by: check REQUEST h) Has this REQUEST been approved by your Elder?

2 Yes _____ No i) Do you agree to provide necessary receipts? Yes _____ No j) Please explain the use for these funds: k) check should be made payable to: Amt. Due: l) check # given: m) Date check was written: n) Date receipts brought in: o) check released by.

3 Your Signature Date Elder s Signature Date s Signature Date Comments: (RECEIPTS MUST BE RECEIVED WITHIN THREE DAYS FROM ISSUANCE OF check ) Please place in Financial Administrator, Sis. Karen Gordon s Mailbox Please allow 7-10 business days for check reimbursement STOP!

4 Do not fill out lines e-g FOR OFFICE USE ONLYSTOP! Do not fill out lines l-o FOR OFFICE USE ONLY