Southside Rotary

Reimbursement Request

Requested by: ______________________________ Date: ________________________

Make check payable to:____________________________________________________

Please reimburse me for a total of $ ____________________________ for the following:

#	Item Description and Justification	Amount	Please indicate Category (for example Flag Project)
1
2
3
4
5

Signature of Requestor:_____________________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

To be completed by Treasurer:

Board approved item: Yes ¨ No ¨ (If no, require board action)

Date Received: ____________________________

Date Check issued: ____________________________ Check #:__________

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