Department of Work: _____________________________________

Date: _________________________________________________

Please Issue Check To:   __________________________________

______________________________________________________
(Person or Firm)

To Be Charged to Budget Item Number: ______________________
Itemize Expenditure in Detail:

__________________________________________  $ _________

__________________________________________  $ _________

__________________________________________  $ _________

__________________________________________  $ _________

__________________________________________  $ _________

__________________________________________  $ _________

__________________________________________  $ _________
                                                                TOTAL: $ _________

 (Attach All Invoices and/or Receipts)

_________________________________________
(Signature)

______________________________________________________
(For Bookkeeper’s Use ONLY)

Date Received _______________                 Check No. _______________

 Date Paid _______________          Budget Account No. _______________