Statewide Parent Advocacy Network, Inc.

Check Payment Request Form

Use this form to request check payments to vendors for items other than supplies, library materials, or staff member reimbursements.

Check requested by:

Grant(s) to be charged:

Grant(s)	$ to Grant
TOTAL AMOUNT

Check to be made payable to:

Check amount:

Mail check to:

Contact Name:

Company/Organization:

Address:

City, State Zip:

Note: All invoices and/or completed order/registration forms should be attached.

APPROVED BY: _________________________________

Project Director/Coordinator

______________________________________________________________________________

FOR FISCAL USE ONLY:

Date reimbursed __________ Check # ________________

Executive Director/Associate Director ____________________________ Date_____________