| 1. Payee Name | |
| 2. Total Reimbursement Amount | |
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3. Explain the reimbursement a. What we are reimbursing b. Why the purchase could not be made with proper purchasing methods c. The urgent need for the purchase |
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| 4. Justification/purpose for need on project | |
| 5. *Account/Project |
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*Indicates information needed from PI/Supervisor