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Jack and Jill of America, Inc.

Western Massachusetts Chapter

CHECK REQUEST FORM

Please complete the following:

Date of request: _______________________

Name of requestor: ________________________________________

Email:_____________________ Phone: ____________________

Make check payable to: ______________________________________

Address: __________________________________________________

Check amount: $____________________________________________

Description of purchase/items: _______________________________

__________________________________________________________

__________________________________________________________

Name of event or committee: _________________________________

Requestor’s signature: _______________________________________

All receipt(s) Must be attached to this form if items have already been purchased.

If purchase has been approved but not yet made, please submit receipts as soon as possible.

TREASURER’S USE ONLY

Date: Check #: Check Amount:

Approved by: Treasurer’s Initials: