REIMBURSEMENT / DISPERSEMENT FORM

Date of request ________________________________________

Person making request: __________________________________

Purpose of expenditure __________________________________

Approvals: ___________________________________________

Music Department:                                   

              (Approval needed for only for disbursement relating to music department activities)

Boosters: _________________________________________________________

                                                         (President or Treasurer)  

Receipt attached: ______________________________________ 

Make check payable to: _________________________________

Mailing address

Name:  ______________________________________________

Address:  ____________________________________________

City: ________________________________________________

Amount of check:     ____$___________________

Invoice Number:  __________________________

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Treasurer’s use:

Check number:   _______________   Amount: ____________

 Date Issued:______________  Budget Category:_____________

 Entered:                                 Check Returned: