Iia-st. Louis Chapter Payment Request/Expense Reimbursement Form

IIA-St. Louis Chapter

Payment Request/Expense Reimbursement Form

Tawana Turner

Wells Fargo Audit Services

One North Jefferson Ave.

MAC H0003-034

St. Louis, MO 63103

Phone: [phone]

Fax: [phone]

[e-mail]

Only for reimbursements over $500

TO:

John Drury

RubinBrown

One North Brentwood

St. Louis, MO 63105

Phone: [phone]

Fax: [phone]

[e-mail]

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


See Attached

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 7/13/15)