Columbus Area Down Syndrome Support Group

Check Request/Reimbursement Form

Contact Information:

Name_______________________________ Phone_____________________ E-mail______________________

Address__________________________________________________________________________________

Check Request Information:

Check Payable To: __________________________________________________________________________

Amount :_________________________________________________________________________________

Explanation: _______________________________________________________________________________

Mailing Information (if different from contact information): ____________________________________________

_________________________________________________________________________________________

$______ NDSS Affiliate Membership $______ NDSS Annual Contribution $______ Administrative $______ Newsletter $______ IDSC for Public Policy Contribution $______ STEP (Teens/ Young Adult Group) $______ Morning Coffee Group $______ DADS Group

$______ Buddy Walk $______ Meeting Expenses $______ Sitter Gifts $______ Sunshine Packages $______ Lending Library (Resources/Library) $______ Scholarship Fund (Conf./Reg. Fees) $______ PO Box Rental $______ Webpage

Total Request for reimbursement:

$__________________________ Signature:__________________________________

NOTE: Attach Receipts/bill and Mail to: Helen Milvert

CADSSG Treasurer

3447 Briar Dr.

Columbus, Indiana 47203

Treasurer Use Only:

Approval: __________________________ Date: ___________________

Date Mailed: ________________________ Check No. ______________

Amount: ___________________________________________________

Copy Forwarded to ARC on ___________