TI D17 Reimbursement Form 11 by D5D29A5

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									                                                                         DISTRICT 17 REIMBURSEMENT FORM
Submitted by:                                                 NAME:
Name:                                                         ADDRESS:                   STREET
                                                                                         SUBURB
                                                                                         STATE                                                             POSTCODE:
Date Submitted:                                               CONTACT TELEPHONE:



                                                                                                                                                   Internal Use Only
                                                                                                                                           Cost Centre       Budget Line Item
        Date           Ref No.            Supplier                              Description/Type of Expense                                                                                  Amount
                                                                                                                                            Number              Number


                          1


                          2


                          3


                          4


                          5

TOTAL CLAIMED                                                                                                                                                                            0.00
     Please Attach a Tax Invoice or Receipts for goods or services provided by a supplier.                Invoices need to be submitted within 60 days.

Complete if Direct Bank Account Credit is desired:                                           Amount:                                                            Claimant Signature:

     BSB:                                                                                                      0.00
     Account Number:                                                                         Has this been paid?
     Account Name :                                                                              Yes No

                                                                                                                                                                District Governor's Approval:
     District Treasurer's Use Only :
                                                                                                                                                                I approve this payment and confirm that it has
     Date Paid:                                                   GST                                                                                           been included in the District Budget processes.


     Cheque No:                                                                                                                                                 District Governor's Signature
                                                                Treasurer's Signature:


     EFT Authorisation Reference:                                                           Dietmar Mazanetz

                                                                                                                                                                                         Ross Wilkinson


     This form must be completed and submitted to the District Treasurer for payment to proceed.

                         By Post:                                                                                                                               By Email:
                         Complete form: print, attach tax receipts or invoices and post to:

                         Treasurer, District 17                                                                                                            dietmar@mazanetzspeck.com.au
                         PO Box 6
                         Mosman Park, 6912

								
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