imprest fund claimsform by HC120831111649

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									FORM 34-AEH-24 REV. 12/03          LOS ANGELES UNIFIED SCHOOL DISTRICT
STK NO. 9661213465                              Accounting and Disbursements Division                 *CODE to describe type of material purchased:
           ORIGINAL                                 Accounts Payable Branch                           1. Textbook               7. Instr. Media Material
                                                                                                      2. Library Book           8. Non-Instr. Supplies
                                                                                                      3. Instr. Supplies        A. Audio Visual Equipment
                                        IMPREST FUND - CLAIMS FORM                                    4. Repl. Of Equipment    B. Library Equipment
                                                                                                      5. Equipment (Other)


PAY TO                                                    /                                              DATE:
                     (Name of Administrator)                    (Vendor Code of Administrator)
CHARGE SCHOOL
  OR OFFICE:                                                                                             AREA/ORGN CODE:
LOCAL DISTRICT:

                        FUND/          *Code
DATE OF  QTY.           PROG.          (See                          DESCRIPTION                                   CHECK UNIT                  TOTAL
INVOICE REC'D           CODE           Above)                                                                     NUMBER PRICE                AMOUNT




                                                                                                                          TOTAL           $           -

      Claim must be signed by the person to whom the fund wasissued, and should agree with "PAY TO" field at the top of this form.
      This claim should be reviewed and the material listed thereon authorized as described in the Imprest Fund Reference Guide.

      I certify that the above statement is correct and that all materials listed thereon have been received. I further certify that
      there is no profit of any kind for me in this claim and that it is in accordance with Section 60071 of the Education Code.


  For Accounts Payable Branch Use Only:                                      NAME AND SIGNATURE OF ADMINISTRATOR
  Fund     Program     Object        Amount

                                                          Requests should be forwarded, in duplicate, to Accounts Payable Branch - General Payment
                                                            Unit, Accounting and Disbursements Division, 333 So. Beaudry Aveune - 27th Floor.


  Total                            $       -                                                                IF CLAIM NO.       _______

								
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