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<br />STATE OF FLORIDA <br /> <br />CITY OF ZEPHYRHILLS <br /> <br />PASCO COUNTY <br /> <br />DISBURSEMENT REQUEST - REi'UNDS 6;, MISCELLANEOUS PAndENTs <br /> <br />- .:1// ir+ <br /> <br />TO, JlCCOllNTING 1R<>>4, lil j dd Vu ITr <br />(DEP. ) <br /> <br />JIhKlUNT, JJ50 - Of..' (c.l/Jeh!dt'J ~,OO fJt -1m { fil t- ~ uD JidMR. /1J J <br />PAYABLE TO: _ 6/l L R O~b I!. s; L IJ <br />T f\rzl G atl 0,0 S E r<... r) j CE ~{."!rJSf-flLLI117 ()rJ <br />~4 c, c.- if'] i 'J5u.sf{ NS L ( _ I {.C 3 35'/ :3 <br /> <br />'VENDOR' : <br /> <br />REASON FOR PAnIENT: <br /> <br />rVVru:t "* g I (17 -t04U (J cLu 1 JAJLl'h, .A rich-QO ~ <br />CfjL~UI !scULwc1t'ci1~ r Pye.a~ /LeJ--t~/~ (J'LfrrU)LuJ <br />{Jb ~ O. u 0 ~ 10 c:tr'} i'1{l~ttJ1 . <br /> <br />CHARGE TO ACCOUNT' <br /> <br />o { - .5:2~ - (JU I..~ <br /> <br />REQUESTED BY: <br /> <br />--> 2 <br />I.)~ l-J V1~7 )"'--. <br />(Signature) <br /> <br /> <br />APPROVED BY: <br /> <br />ACCOUNTING USE ONLY: <br /> <br />Paid Date: <br /> <br />Check . <br />