American Lawyers Alliance

Expense Reimbursement Form

Please ensure that your have approval from your committee chairman for this reimbursement before you submit this form.

Sharon Chappelear, Treasurer

740-927-5054

sschappelear@hotmail.com

2756 Patterson Road S.W., Pataskala, OH 43062

Date:

Amount:

Pay to the Order of:

Mail Check to:

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Expenses: (Please attach any substantiating receipts or bills)

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Purpose:

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Amount:

Purpose 1:

Amount 1:

Purpose 2:

Amount2:

Purpose3:

Amount3:

Purpose4:

Amount 4:

TOTAL:

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By checking above, I certify that I have approval for this reimbursement by my Committee Chairman. (Subject to verfication)

Signed and submitted by:

Committee or Office:

Approved by:

Committee Chairman:

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Please note : All In-KInd donations, money donations, and all donations of time should be reported below:

In-kind donation description

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