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'� <br />CITY OF ROSEVILLE <br />REQUEST FOR PAYMENT <br />A Purchase Order is required if request exceeds 52,000.00 <br />Please PRINT neatly. Thank You. <br />Date <br />Check Needed By <br />Vendor Name ( heck will be made payable to this vendor) <br />fi� VI �I �( ��, I 1� r/1 —� .. <br />Vendor Address <br />Street Address <br />r <br />V � � �� <br />� I� ��i�wm � l�,�o�' <br />State <br />For Payment (Attach Necessary Backup Information such as receipts, etc.) <br />�Z�1 I��144d�v �SC-tldu ) .�'�S �� <br />Account Numbers <br />)o-bo -C�o -Oo�p � <br />Person Requesting Check <br />Department Head Approval <br />Amount <br />.�2�a ��� .b <br />Finance Department Approval for Check to be Made Out Prior to Council Date <br />\\Finance\Forms\Request For Payment.doc <br />