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CHECK REQUEST FORM
The original
receipt or a copy of the original or invoices MUST accompany all Requests for
Reimbursement. Please attach receipts or an invoice to the completed form. A
separate form must be used for each receipt.
Date:
_______________________ Invoice/Receipt Attached: _________
Invoice
To Be Mailed: _________
Requestor’s
Name:________________________________________________
Event:___________________________________________________________
Item(s)
Purchased:______________________________________________________
Date of Purchase: __________________ Amount: __________________
Vendor:
_________________________________________________________
Tax ID#:
_____________________ or SSN: ___________________________
New (?): Attach
W-9 _______
Make Check
Payable to: __________________________________________
Address:
________________________________________________________
_____________________________________________________________
_____________________________________________________________
Signed
by
Requestor: _______________________
Fin. Coord: _________________________
President's Signature (if greater
than $200):__________________________________
SEND TO: WVSO FINANCE
Sheila Ashley
One Clay Square
Charleston, WV 25301
561-3530 (O); 561-3598 (fax);
sashley@theclaycenter.org
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(For WVSO Finance Use Only)
Check # __________ Date ___________
Account # ___________________
Signed
by:_____________________________
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