************* Attach Receipts/Documentation to Reverse Side of Form

CHECK REQUEST

UNITED CHURCH IN WALPOLE

Payment Request Amount:_________________________Date:__________________

Check Payable To: ____________________________________________________

Payee Address:________________________________________________________

City:______________________________________ State:_______Zip:____________

Purpose of Payment:_____________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Payment Requested By:

________________________________________Phone:_______________________

_________________________________________________Committee/Activity Name:

Disposition of Check:

            Mail to Payee:_________           Leave in Office Mail Slot:_________