Check Request Form

* Indicates required field.

Date*

mm/dd/yyyy

Make Check payable to:*

Choose only one*

Return Check to Requester

Mail Check to Requester (enter complete address below)

Mail Check to this Address

Address 1

Address 2

City

State

Postal Code

Country

NO CHECK WILL BE ISSUED UNTIL INVOICE(S), RECEIPT(S) OR RECEIVING DOCUMENT(S) ARE ATTACHED TO THE CHECK REQUEST/PURCHASE ORDER FORM.

Charge to Account #:*

Description of expense*

Amount*

Sales Tax info*

No sales tax

Sales tax below

Sales Tax Amount

Total Check Amount*

PAYMENT AUTHORIZATION / VERIFICATION*Mark all that apply...

Authorized person's names requesting expenditure

Check Request Form / Purchase Order

Board Minutes

Signed Contract

Regular operating expenses (gas, water, electric, etc.)

INVOICE ATTACHED?*

Yes

No (if no, attached Receiving Document)

Authorized by: (entering name here is same as signature)*

Signature Date*

mm/dd/yyyy

Westminster Good Samaritan