CHECK DISBURSEMENT VOUCHER

Date:	_______________	Amount:	________________
Payee:	_________________________________________
Address:	_________________________________________
	_________________________________________
City, State & Zip:	_________________________________________

INVOICE DATE	INVOICE NUMBER	FUND	ORG	ACCOUNT	PROG	NET AMOUNT
					TOTAL:
DESCRIPTION:

DEPARTMENT APPROVAL (must include printed name and e-mail)	SPECIAL INSTRUCTIONS
__________________________   ____________ Signature   Date PRINTED name:  _____________________________ E-mail address:  _____________________________

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