Fillable Name Address City State Zip C. (Motlow State Community College)

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Name Address City State Zip C. (Motlow State Community College)

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A. MAKE DISBURSEMENT TO: B. DATE:
Name
Address
City State Zip
C.
ACCOUNT NUMBERS: (Note: Only the Banner Index & Account is required except for funds that begin with an 8xxxxx OR 9xxxxx)
ACCOUNT FUND
PROG
D.
PURPOSE / DESCRIPTION: (Also, please attach original receipts and / or invoices)
E. MAILING AND OTHER INSTRUCTIONS:
F.
%8'*(7$5<+($' NAME & PHONE NUMBER:
G. A
PPROVALS:
(legible signatures as applicable)
Budgetary Head Approval: Date:
Department Approval (as necessary) Date:
Vice President Approval: Date:
President Approval: Date:
H. PETTY CASH RECEIVED BY: Date:
Vendor # 1099 Vendor Date Due
DISBURSEMENT REQUEST
(PLEASE USE ELECTRONIC FORM AND PRINT)
Banner Information
Amount Invoice Date Invoice #
Office Use Only
INDEX
ORG
TOTAL AMOUNT
FOR BUSINESS OFFICE USE ONLY
_____ Petty Cash _____ A/P _____ Direct Deposit _____ JV
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Name Address City State Zip C. (Motlow State Community College)

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Completed 27 July 2020

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