Proposed Washington County Wellness Initiative’s Rural Health Network Development Planning Grant Program Policies and Procedures
2014
REQUEST FOR PAYMENT FORM Payable to: Address: Street
City
Amount:
State/Province Country
$
Zip/Postal
Charge to:
Purpose: Instructions: Requested by:
Date Requested:
Approved by:
Date Approved:
Approval Signature: Processing Policies:
Request for Payment Form must be approved by the authorized person responsible for the budget item.
For Accounting Use Only G/L Account#: Date Paid: Check#: Check Amount:
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