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: ________________________________________________________________