Purchase/Check Request
Person Requesting
*
Maureen Hyatt
Jessica Williams
Brenda Greer
Nathan Carter
Ally Holtrey
Type of Request
*
Check
Purchase Order
Online Purchase Request
Vendor
From where are items being purchased?
Date Needed
*
-
Month
-
Day
Year
Date
Expense Code
*
Please Select
604- Utilities
605- Telephone
606- Security
607- Pest Control
608- Maintenance
609- Cleaning Services
610- Insurance
611- Unit Supplies
612- Office Supplies
613- Transportation Assistance
614- Processing Fees (Background Checks, Drug Screening, Etc)
615- Appliance & Furniture Replacement
616- Fundraising, Marketing, Postage
617- Computer Services
618- Emergency Shelter (Hotel Stays)
619- Diversion Assistance (Rent)
620- Outreach/Prevention
621- Client Support
622- Staff Training
623- Professional Services (Memberships, Accountant, Etc)
630- Employee Travel Reimbursement
683- Payroll Tax Expense
684- Bank & CC Fees
OTHER
Trip Details
Total Mileage
Mileage Reimbursement Amount
Do you have other travel related expenses?
Yes
No
Total Amount of Other Expenses
Attach of copy of receipts to completed form
Total Amount of Reimbursement Request
Check(s) Requested
Make Check Payable To:
Amount
Client Name/Reason
Check 1
Check 2
Check 3
Check 4
Requested Items to be Purchased
Reason:
Estimated Cost
Method of Payment
Credit card (preferred)
Cash
Submit
Should be Empty: