SusannaDickinsonPTO
CheckRequestForm
Please contact [email protected] with any questions.
1) Complete the check request portion of this form and attach all detailed receipts. The Dickinson Elementary School PTO is a taxexempt organization. Please obtain and use a tax-exemption letter when purchasing items on behalf of the PTO. The tax exemption
form may be found at www.dickinsonpto.com . The PTO CANNOT reimburse for sales tax.
2) Place this form in Dr. Mumphord’s box for approval.
3) Look for this form to be returned to you after Ms. Mumphord has approved your request.
4) Place this form and receipts in the PTO treasurer’s mail box. Please allow up to 2 weeks for reimbursement.
Check Request
Staff Name: _______________________________________ Email: ______________________________________ Date: _________________
Grade Level/Dept: ________________________________________________________Date Needed: __________________________________
Item(s) Requesting:
Cost:
1. ___________________________________________________________________________________________
$______________
2.____________________________________________________________________________________________
$______________
3.____________________________________________________________________________________________
$______________
4.____________________________________________________________________________________________
$______________
5.____________________________________________________________________________________________
$______________
6.____________________________________________________________________________________________
$______________
7.____________________________________________________________________________________________
$______________
8.____________________________________________________________________________________________
$______________
9.____________________________________________________________________________________________
$______________
10.___________________________________________________________________________________________
$______________
Total Amount requested
0.00
$______________
Item(s) to be used for: __________________________________________________________________________________________________
Make check payable to: _________________________________________________________________________________________________
Mail to:
□ Teacher Mail Box □ Child’s Teacher Mail Box: ________________________ □ Other: _________________
□ Following Address: ______________________________________________________________________________________________
Please choose a category:
□ Classroom Funds □ Grade Level Funds □ Field Trip □ Specials
□ Department: ________________________________ □ Other: ____________________________________________
FOR PTO USE ONLY:
Principal Approval:_____________________________
Dickinson Elementary PTO Check Request Form
PTO Approval:____________________________________
Date Updated 06/16