check request form

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CHECK REQUEST FORM 3899 John Tyler Highway Williamsburg, VA 23185-2400

PAYEE:

MINISTRY/PURPOSE:

Name:

Ministry:

Address:

Purpose:

City/State/Zip:

Account # - Project Code #:

Amount:

Please mail: Check will be Picked up (where):

Date Due:

Supporting Documentation (check as appropriate and attach document) Purchase Order required if over $1,000 - Please attach Copy If Applicable

Receipt/Invoice: ________________________

Payment in Advance:_____________

Service Complete & Satisfactory:____________ Other: _______________________________________________________________

APPROVALS: two signatures required Payee/Requestor:

Supervisor's Approval (Staff Only):

Printed Name:

Printed Name:

Signature:

Signature:

Date:

Date:

Purchases over $1,000 require additional signature of either Finance Director, HR Director, Support Service Director

Printed Name: Signature: Date:

Purchases over $2,000 require additional signature of either Finance Director, HR Director, Support Service Director and one additional from a member of the Leadership Team

Form Fin-008 (Rev 9/15)

Printed Name: Signature: Date: