Picn*x XV - Request for reimbursement of cash expenses

Please return with copies of the receipt(s) to the Treasurer.  Neither receipts without
form, nor form without receipts shall be accepted.

Return forms and receipts to:

Justin Rocha
2135 Bidwell Ave.
Chico, CA 9596
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Your Name:            

Mailing address:      


Date:                 

Receipt
no.   | Amount | Date  | Vendor             | Description of items bought
______|________|_______|____________________|________________________________
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
      |        |       |                    |
______|________|_______|____________________|________________________________ 


Total:      $_______   Number of receipts: ________


Additional information, if needed:







For treasurer's use: reimbursed with check #______________.