4-H CLUB CHECK REQUEST FORM
(Please remember to try and use your card first as a form of payment)
Name of Club: _________________________________________________________________
Club Account Number: __________________________
Date: ________________________
Name of Person or Business to receive check:
______________________________________________________________________________
Address: ___________________________________________________ Zip: _____________
Social Security or Tax ID Number (if gift over $100; not needed for reimbursement):
___________________________________________
Purpose of request: (for example: award/gift, reimbursement, etc.) Be specific.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Amount of Check: _______________________
Requested by: _________________________________________________________________
Request must be accompanied by the original detailed receipt or a written request for an
award/gift. All food purchases must be accompanied by a list of attendees. All requests
must have documentation submitted with this form.
Please send this form and the accompanying paperwork to your local 4-H office.