Rotary Club of Utica

Voucher for Payments and Reimbursements:

Requested by: ________________________________________

Date: ____________________ Amount: ___________________

(Attach receipt)

Write check to:

Name: ___________________________________________

Address: _________________________________________

City, State, Zip: ___________________________________

Distribution of expense to:

____________________________________________________

Requestor’s signature: ________________________________

 

 

Paid by Check # ____________ Date: ___________________

For payment, return completed form to Carol Gilberti, Lennon-W.B. Wilcox Co., 4571 Commercial Drive, New Hartford, NY 13413