Fiduciary Trust Account
Authorization for Expenditure of Funds
DATE ___________________________ HOLD MAIL
This is your authorization to make a check payable to:
NAME __________________________________________________________________________________________________
ADDRESS _________________________________________________________________ PHONE # ____________________
CITY _____________________________________ STATE ________________________ ZIP __________________________
ACCOUNT TO BE CHARGED _______________________________________________________________________________
DESCRIPTION
Quantity
Unit
Price Amount
SUBTOTAL
TAX
Shipping
Information/Documentation
Required:
Description/Details of
purchase/service rendered
Date & location of proposed
activity
Attach any
Original Receipts/Invoices
FAILURE TO PROVIDE
THE ABOVE MAY CAUSE
DELAYS IN PROCESSING
TOTAL
$
Requested By ___________________________________________ Phone ________________________________
Account Custodian Approval ___________________________________ Date ______________________________
Check Number _______________________________________ Check Date _______________________________
Received By __________________________________________ Date Rec’d/Mailed __________________________
