Date Submitted:_____________________________________________________________________________

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From: ______________________________________________________________________________________

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Phone Number:_____________________________________________________________________________

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Office or Committee:________________________________________________________________________

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Amount:____________________________________________________________________________________

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Payable to:__________________________________________________________________________________

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For:_________________________________________________________________________________________

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_____________________________________________________________________________________________

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_____________________________________________________________________________________________

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_____________________________________________________________________________________________

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Please attach all receipts.

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Date paid:__________________________________________

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Check #:____________________________________________

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Category:___________________________________________