Reimbursement Form

GENERAL BUDGET ALLOCATION FORM * Please do not make purchases for reimbursement without prior consent of an Elder * Date _______ / _______ / _______ Submitted by __________________________________________________ Commission ___________________________________________________ Title __________________________________________________________ Budget Line Item (if known) ______________________________________ Check Payable to / (or Vendor) ____________________________________ In the Amount of $ ___________ Date Needed _____/_____/_____ Rationale / Or Further Instructions: ________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Will be billed ______________________ Date Ordered _____/_____/_____ Submitted to Credit Card _________________________________________ Authorized by _____________________________ Date _____/_____/_____ (If possible, please attach all invoices or purchase orders to this form. Place in the Treasurer’s Box, Patty Hack. Thank You.)