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    JANE ADDAMS PTSA
    Check Request/Reimbursement Form

    Check Request - Reimbursement Form 2016-17.jpg

    Name (of requesting party): _______________________________________________

    Check payable to (if different): _____________________________________________

    Address: ________________________________________________________________

    ________________________________________________________________________


     

    Phone #: _______________________________________________________________

    Room #: __________ E
    mail:____________________________________________


    Date 
    Description
    Amount

    ______________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    TOTAL________________

    1. Please complete this form and attach all relevant receipts
    2. Submit to Treasurer or put in the Treasurer's PTSA Box
    3. Note what you want done with your check:
    ____Put in my Box
    ____Mail it to me
    ____Other ____________________________________________________________

     


    For Treasurer's Use:

    Date_______________ Amount__________________
    Check #____________ Category_________________