Check Request Form Template

Use a separate form for each payee.
Receipts, invoices and/or other supporting documentation must be attached.

Make check payable to:	

Date	Use of Funds	Amount
Requested:	

			

Total	$	

If check is to be mailed, where should it be sent?
Address 	
City 	 Zip	

Signature 	 Date	

		
(For the treasurer’s use only)

							Approved: _________
Date	Check #	Acct. #	Account	Amount	
			Checking	$	
					
	split				

Reimbursement Voucher

Make check payable to: 	
Date	Item	Place of Purchase
(if appropriate)	Amount
Requested	
			$	

		Total	$	

Account to be credited:  	
Explanation:	 

	
Certification:  The expenses listed above were incurred in connection with authorized ________________________ and were not otherwise reimbursed to me.

Signature 	 Date	

(For the treasurer’s use only)
			Approved : _________
Date	Check #	Acct. #	Account	Amount	
			Checking	$	
					
	split