1. Please print your name, address, and phone number in the first table.
2. Fill in the date, brief description, and cost from each receipt to clearly document your expenses in the second table.
3. Fill in the total of all expenses in the bottom line in the second table.
4. Provide a clear copy of each receipt listed on the report, stapled to the report.
5. Sign and date the report.
6. Keep a copy for yourself, and send a copy to the BHC Chairman.
7. The BHC Chairman will keep one copy for the BHC records, and will submit the other copy to Rena in the Selectmen's Office in the Town Hall.

NAME:

ADDRESS:

DATE

DESCRIPTION

COST

DATE

SIGNATURE

Last updated 05/20/05