SHS - Disbursement Request

I. DEPARTMENT CODE

SHS MGMT & GENERAL
SHE SHS Enterprises
CEO CEO Office
MKT Mktg & PR
PDA Prog Dev / Advocacy
MSO MSO Office
FIN Finance
HRD Human Resources
ICT Info & Comm Technology
FCMN Facilities Maintenance
PRM Property & Risk Mgmt
SHBD SHS Board
RDW Redwood Project
Other:
ALAMEDA COUNTY (BAYC)
Dept Program Mental Health
Executive BAYC BAMH
Esser BAG2 BMHE
THPP/RAFA BATH BMHR
THP+ / SHP BATL BMHS
TEXP BAYC Temp Restr Grant Exp / FUNDRAISING
DEV Development Ofc
DML Direct Mail
SPV Spcl Evnts - Other
GLA Gala Event
GLF Golf Tourn
MVB Valentines Ball
SAM Sam’s Event
Other:
(VF/Aux/Guild Name)
SONOMA COUNTY
SKN Kinship
XKSSP Shared King St Costs
SFST FASST
SAMH ACT
SYD CEYD Comm Eng Youth Dev
SPRD Project PRIDE
STBS Sonoma TBS
TEXP CEYD Temp Restr Grant Exp
TEXP KSSP Temp Restr Grant Exp / MARIN COUNTY
BDT Braun
GDT Grant Grover
BC Blended Clssrm
TBS Marin TBS
MCR CARE & Respite
MARIN ACADEMIC CENTER
MAC General
TTL Title I
NPA NonPublic Agency
TEXP MAC Temp Restr
Grant Exp
MENTAL HEALTH ADMIN
SHMH SHS Mental Health
across counties
Other:
(see Accounting for Dept code)

II. CHECK OR EFT DISBURSEMENT DATA

Note: invoices and/or receipt must be attached for payment or reimbursement

Date of Request / Payee’s Full Name and Address, must include zip code / Amount / Due Date (see instructions)
Mail check to Payee Mail check to payee with attached papers / in attached envelope
Interoffice to: Electronic Funds Transfer:
(Name/SHS Program/Location) Re-loadable Debit Card
EFT Vendor
(Note: First time EFT pmts require advance set up)
Comments / Special check handling instructions:
Description/explanation of expense:
G/L CODE (see see Form SHS-M001 for Codes):
note: if you are using the 8299 or 8499 code in your category, you MUST provide a clear description of the expense as well as providing the code number in the line above. / Special Grant or Other Coding:
Submitted by:
(signature here)
Printed Name: / Authorized by:
(Department Head signature here)
Printed Name:

For Accounting Use Only:

DIST OR DEPT CODE / G/L / AMOUNT / G/L DATE

SHS-A001 (SHS Disbursement Request) 1

Rev 072409jc