Hammond Middle School PTA
Disbursement Request

Date: ________________________

To the Treasurer:

Pay to the order of: ____________________________________________________________________

Amount: $ ____________________. ______

_____________________________________________dollars & __________________cents

Charge to the account of: ________________________________________________________________

Purpose: ____________________________________________________________________________

Itemized expenses:

___________________________________________________________________________________

Total: $___________.____

Requested by: _________________________

(Your signature)

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(DO NOT WRITE BELOW THIS LINE)

Paid by check No.: ________________________ Date: ______________________

Issuing officer: ______________________________

(signature)

_____________________________

(title)