Check Request Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Check Request Form

**Date of Request:** {{request_date}}

**Requestor Name:** {{requestor_name}}

**Department:** {{department}}

**Contact Phone/Email:** {{requestor_contact}}

Payee Information

**Payee Name:** {{payee_name}}

**Payee Address:** {{payee_address}}

**Phone Number (if applicable):** {{payee_phone}}

**Email Address (if applicable):** {{payee_email}}

Payment Details

**Amount:** {{currency}} {{amount}}

**Payment Due Date:** {{due_date}}

**Purpose of Payment:** {{purpose_of_payment}}

**Invoice/Reference Number (if applicable):** {{invoice_number}}

**Attach all supporting documentation (invoices, receipts, contract copies, etc.).**

Account Coding

**General Ledger Account:** {{gl_account_number}}

**Cost Centre/Project Code:** {{cost_centre_code}}

**Budget Line Item:** {{budget_line_item}}

Authorization

I hereby certify that the information provided above is accurate and complete, and that the requested payment is for a legitimate business expense.

**Authorized by (Name):** {{authorizer_name}}

**Title:** {{authorizer_title}}

**Date of Authorization:** {{authorization_date}}

For Accounts Department Use Only

**Check Number:** {{check_number}}

**Date Issued:** {{date_issued}}

**Posted By:** {{posted_by}}

**Verification:** Reviewed all documentation and confirmed accuracy.

**Accounts Approval Signature:** _________________________

Signature Block

_________________________

**Requestor Signature**

Date: _______________