Check Request Form

Complete this form to request a check from EPBC.

Your name *

Email address *

PAYEE INFORMATION

Payee Name (Full Legal Name) *

This is the name printed on the check.

Mailing Address *

Street Address, City, State, Postal Code

Phone number *

Note: Check requests remitted after Tuesday will not be available until Thursday of the following week.

Total Check Amount ($)

Amount

Check Return *

Mail Check to Payee Address

Pick-Up Check at Church Office

Other

Approving Ministry Director or Staff Member *

Name of individual who authorized the purchase(s) on this request.

Ministry / Department *

Ministry responsible for the expense(s). If known, please provide the Expense Account Number(s) or Account Description(s).

Explanation of Payment

Reason for Request. e.g. Event Name, etc.

Proof of Payment*

Documentation must include date, amount of transaction, and vendor. e.g. Store Receipt, Invoice.
*REQUIRED for all reimbursements.

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