Prior Advance Balance: $-- - month This Advance: $ 75". O0 Less: Receipts: $ 9.75 r 0 ° Funds Returned and/ or Cash on Hand $- Amount to be Reimbursedi . _ .. . ... / . 27. Document No. I I/ I li if, c 4::t i 1 iti 1 a. Draft No: a Date: , f/ ..../. J 30. Cashier: . „, t, I) ked Shaded are