Request for Payment

Date___________________

PAYABLE TO: (must have complete address)

___________________________________________________

___________________________________________________
AMOUNT: ___________________________________________________

DIVISION: AJLSC Account ____ Dorothy Schroeder Memorial Fund Account ____

PAYMENT FOR: ________________________________________________

_____________________________________________________________

REQUESTED BY: _____________________________________________
(Signature)

AUTHORIZED BY: ____________________________________________
(Signature)

OFFICE OR COMMITTEE ______________________________________

(MAIL COMPLETE FORM WITH ATTACHED RECEIPTS TO THE AJLSC TREASURER)