ABCDEFGHIJKLMNOPQRSTUVWXYZ
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DATE:
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Payee:
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Address:
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For:
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Please see attached reciepts
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Amount:
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Account Code/s:
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Requested by:(signature)
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I hereby certify under penalty of perjury that this is a true & correct claim for necessary expenses
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incurred by me and that no payment has been received by me on account there of:
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Advisor Signature:
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Name
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Approved by:
Date:
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Financial Secretary
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ASB Treasure Signature:
Date:
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Student Name
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Principal Signature:
Date:
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Mrs. Jolene Grimes-Edwards
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Check #:
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warrant #:
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