Name:

Date:

Phone:

Email:

Request Information: Amount:

Cash - or - Check

Date Needed:

Reason/Description:

For Cash, fill in this chart: Cash Qty. Needed

Total $

$20.00

Pick up cash in the school office.

$10.00 $5.00

Return money to the office with a PTO Deposit Form to be locked in a secure location.

$1.00 25¢

($10 rolls)

10¢

($5 rolls)

5¢

($2 rolls)

1¢

(50¢ rolls)

TOTAL: Checks can be picked up in the office or sent home with your child Payable to: □ I will pick up my check in the office. Please call me when it is ready. -or□ Please send my check home with my child:________________________________ class:________________________________ Signature:___________________________________________ *For Reimbursement, Please Use the PTO Expense Form

For PTO use: Date Paid: Check Number: Amount: Payable To: Paid By: