Payment Request/Expense Reimbursement Form

IIA-St. Louis Chapter

Payment Request/Expense Reimbursement Form

TO:

Nathan Croll

RubinBrown

One North Brentwood

Suite 1100

St. Louis, MO 63105

Phone: (314) 290-3250

Fax: (314) 290-3400

Please pay the following approved expense/reimbursement for the following chapter expense. ORIGINAL supporting documentation is attached. Please ensure the payment is received by ______.

Pay to:

Name, Address and Phone ______

______

______

______

Description of Expenditure(s):

______

G/L Account #: Amount: ______

______

______

______

TOTAL AMOUNT OF PAYMENTS: ______

Was expense budgeted? ______YES ______ NO

Other Special Instructions:______

______

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Individual Completing Form: ______Phone: ______Date: ______

Approved by Pertaining Officer: ______Phone: ______Date: ______

Treasurer’s Approval:______Date:______

(Required for transactions exceeding $500)

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Directions: Please complete the form. Attach original receipts or a copy of documentation approving the specific expense (i.e. requests from restricted funds given by the Education Foundation). Forward the form to respective officer for approval, G/L account distribution, and indication as to if the expense was budgeted. An attached FAXED approval from the officer is acceptable. Forward the entire voucher package to the address above. Please indicate the due date of the payment. If an electronic request form is sent and/or electronic approval is obtained, the supporting receipts must be received prior to payment.

IIA Payment Request/Expense Reimbursement Form (Revised 8/21/17)