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Request for Payment
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Make Checks Payable to Requested By
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AddressDate Requested
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City/State/Zip
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Date of ExpenseCommittee
Expense Category		Description of PurchaseAmount of PurchaseExecutive Board Member That Approved
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 Total Funds Requested $ -
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*** PLEASE ATTACH RECEIPTS/INVOICES ***
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Check Number:
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Check Date:
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