Buona Fortuna Lodge #2835
Order Sons and Daughters of Italy in America
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:
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Fill the name of the Payee on the check.
Mail check to:
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Fill the address where the check is to be mailed.
How Many Receipts?
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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:
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Enter description of charges being reimbursed for Receipt #1.
Receipt #1 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #1.
Receipt #2 - Date:
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Enter date on corresponding Receipt #2.
Receipt #2 - Description:
*
Enter description of charges being reimbursed for Receipt #2.
Receipt #2 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #2.
Receipt #3 - Date:
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Enter date on corresponding Receipt #3.
Receipt #3 - Description:
*
Enter description of charges being reimbursed for Receipt #3.
Receipt #3 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #3.
Receipt #4 - Date:
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Enter date on corresponding Receipt #4.
Receipt #4 - Description:
*
Enter description of charges being reimbursed for Receipt #4.
Receipt #4 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #4.
Receipt #5 - Date:
*
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Enter date on corresponding Receipt #5.
Receipt #5 - Description:
*
Enter description of charges being reimbursed for Receipt #5.
Receipt #5 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #5.
Receipt #6 - Date:
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Enter date on corresponding Receipt #6.
Receipt #6 - Description:
*
Enter description of charges being reimbursed for Receipt #6.
Receipt #6 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #6.
Receipt #7 - Date:
*
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Enter date on corresponding Receipt #7.
Receipt #7 - Description:
*
Enter description of charges being reimbursed for Receipt #7.
Receipt #7 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #7.
Receipt #8 - Date:
*
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Enter date on corresponding Receipt #8.
Receipt #8 - Description:
*
Enter description of charges being reimbursed for Receipt #8.
Receipt #8 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #8.
Receipt #9 - Date:
*
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Enter date on corresponding Receipt #9.
Receipt #9 - Description:
*
Enter description of charges being reimbursed for Receipt #9.
Receipt #9 - Amount Reimbursed:
*
Enter amount being reimbursed for Receipt #9.
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.
Notes: If your expense covers multiple events, break out the expenses and total each event in this text box.
This field helps us code your expenses to the correct account in our books. Make your Financial Secretary's job easier, please! :)
Form Submitted By:
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Fill name of person submitting the form.
Signature of Person Submitting Form
*
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Financial Secretary Signature
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President's Signature
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