Check Request Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}} | Web: {{website}}

Check Request Form

Check Request Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}}

Website: {{website}}

CHECK REQUEST FORM

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

**Department/Requester:** {{department_name}}/{{requester_name}}

Payee Information

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

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

**Contact Person (if applicable):** {{contact_person}}

**Payee Phone Number:** {{payee_phone}}

Payment Details

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

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

**Purpose of Payment/Description:** {{payment_purpose}}

**Account/Project Code to Charge:** {{account_code}}

**Attachments (e.g., invoice, receipt):** Please list or attach supporting documents.

Authorization

I hereby certify that this request is for a legitimate business expense and is supported by the attached documentation. I understand that any false information may lead to disciplinary action.

**Requested by:** {{requester_signature}}

**Print Name:** {{requester_print_name}}

**Date:** {{requester_signature_date}}

**Approved by (Supervisor/Manager):** {{approver_signature}}

**Print Name:** {{approver_print_name}}

**Date:** {{approver_signature_date}}

**Approval Status:** [ ] Approved [ ] Denied

For Accounts Department Use Only

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

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

**Prepared by:** {{accounts_staff_name}}

**Date:** {{accounts_staff_date}}

Declaration

I confirm that the details provided are accurate and complete to the best of my knowledge.

**Signature:** _________________________

**Date:** _________________________