UTAH STATE BAR
YOUNG LAWYERS SECTION
REIMBURSEMENT/PAYMENT REQUEST

Date     ________________________

Payee Name: __________________________________________________________________

Address: _____________________________________________________________________

_____________________________________________________________________________

Explanation/Purpose of Expense: ____________________________________________________
______________________________________________________________________________ ______________________________________________________________________________

Breakdown of Expense:

Cost                             Description

____________            ____________________________________________________________

____________            ____________________________________________________________

____________            ____________________________________________________________

Total Reimbursement Amount:   $         ________________________
       Support in the form of Receipts, Statements, Billings or Other Evidence Must be Attached.

Mail Check:                  Hold Check for Pick Up at the Bar Offices:                                  

Requested by:                                                                 Date:                                          
                                           Signature

Approved by:                                                                  Date:                                          
                                           President
                        
                                                                                       Date:                                         
                                           Treasurer

To be Completed by President or Treasurer:
Reimbursement/Payment to be charged against following Young Lawyers Section Account:

1.         General

(a)  Mailing                              (d)   Travel                

(b)  Copying                                    Miscellaneous                  

(c)  Supplies             

2.         Program Committee Name (Specify) ________________________

Utah Bar Approval:  _______________          Account #: __________________________