Order Sons of Italy in America

Buona Fortuna Lodge #2835

Check Request Form

Date Request Submitted:*

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Function or Event:

If applicable, enter the function or event this request is related to.

Issue check to:*

Fill the name of the Payee on the check.

Mail check to:*

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How Many Receipts?*

Enter number of receipts for reimbursement, up to 10 per check request.

Receipt #1 - Date:*

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Enter date on corresponding Receipt #1.

Receipt #1 - Description:*

Enter description of charges being reimbursed for Receipt #1.

Receipt #1 - Amount Reimbursed:*

Enter amount being reimbursed for Receipt #1.

Receipt #2 - Date:*

/ /

Enter date on corresponding Receipt #2.

Receipt #2 - Description:*

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Receipt #2 - Amount Reimbursed:*

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Receipt #3 - Date:*

/ /

Enter date on corresponding Receipt #3.

Receipt #3 - Description:*

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Receipt #3 - Amount Reimbursed:*

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Receipt #4 - Date:*

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Enter date on corresponding Receipt #4.

Receipt #4 - Description:*

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Receipt #4 - Amount Reimbursed:*

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Receipt #5 - Date:*

/ /

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Receipt #5 - Description:*

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Receipt #5 - Amount Reimbursed:*

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Receipt #6 - Date:*

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Receipt #6 - Description:*

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Receipt #6 - Amount Reimbursed:*

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Receipt #7 - Date:*

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Receipt #7 - Description:*

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Receipt #7 - Amount Reimbursed:*

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Receipt #8 - Date:*

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Receipt #8 - Description:*

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Receipt #8 - Amount Reimbursed:*

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Receipt #9 - Date:*

/ /

Enter date on corresponding Receipt #9.

Receipt #9 - Description:*

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Receipt #9 - Amount Reimbursed:*

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Receipt #10 - Date:*

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Enter date on corresponding Receipt #10.

Receipt #10 - Description:*

Enter description of charges being reimbursed for Receipt #10.

Receipt #10 - Amount Reimbursed:*

Enter amount being reimbursed for Receipt #10.

Total Reimbursement Requested*

This field calculates the total amount requested for reimbursement.

Form Submitted By:*

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Signature of Person Submitting Form*

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Upload Receipts*

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Financial Secretary Signature

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President Signature

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Required Receipts