Please Provide:

Expense Account to be  charged: ___________________________________________________

Council Requestor (if different from payee):  ________________________________________

Date of Expense:  ____________________

Amount: ________________

Purpose (in detail) ________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

Make check payable to:  ___________________________________________________________________________

This section  for Council #17824 use only

Voucher #  _____________     Check #:  __________     Date:   _________________