Bellows Spring Elementary School PTA
Request for Disbursement
TO BE COMPLETED BY REQUESTOR:
Date:___________________________________________________________________
Pay to the order of: _______________________________________________________
In the amount of: _________________________________________________________
To pay for: ______________________________________________________________
Your Signature: __________________________________________________________
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TO BE COMPLETED BY PTA OFFICERS:
Authorized by: _____________________________ Title: ________________________
Date Received: ____________________________ Budget Account: ________________
Amount: _____________________ Check Number: ____________________________
Date Paid: _______________________________________________________________
Paid by: ________________________________________________________________