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MASTERCARD / PHILLIPS / TEXACO / WAL-MART

(Please circle one if this is a credit card purchase)

First United Methodist Church
Chanute, Kansas
Designated Funds Voucher
Name of merchant:
Address:
City:

State:

Zip:

Date funds are requested (circle one): As per statement, or _____________________________
Date

Merchandise or service purchased:

Amount:

I certify the supplies or services indicated above, with invoice attached, have been obtained and
properly charged to the board, committee, or work area budget line item(s) indicated below.

Signed:

Amount
$

Designated Account #

and name