Date:

Submitted By:

Ministry or Special Emphasis Name:

Check Request Type:
AdvanceVendor InvoiceReimbursement

Is this a Budgeted Item:

Purpose of Expenditure:

(All receipts, proposed contractual agreements and anticipated expense statements to support this request must be attached to this form.)

CHECK INFORMATION:

Name of Payee:

Address (if applicable):

Amount of Check: $

Payment Due Date:

****Reimbursement Checks are available fifteen business (15) days from receipt by finance office. Please plan accordingly. All other Check request processing is a minimum 30 days.*****

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