DACC REQUEST FOR PAYMENT
Pay: _________________________________________ Date: _______________________________
Mail To: _____________________________________ Total Amount of Check: $_______________
PURPOSE: AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
AMT.$ ACCT.#
Requested By:
Approved By:
PRE-TRAVEL ADVANCE $________
ACTUAL TRAVEL EXPENDITURES:
Miles at
.575/Mi.
$
AIRFARE $
LODGING $
MEALS $
REGISTRATION $
INCIDENTALS $
Less Advance: $
$ DUE EMPLOYEE $
REFUND TO COLLEGE $
PROCESSING INSTRUCTIONS –
CHECK
THOSE THAT APPLY:
Enclosures:
Mail to above address
Return check to cashier for pick-up
Send check to person initiating request
Other
Receiver Information:
Goods and services described above were verified and received by:
Signature
0
0.00
06/17/2020
0.00
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