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["CHECK REQUEST"]
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[]
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[null,"Requestor's Name:"]
[]
[null,"Mailing Address:"]
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[]
[]
[]
[]
[null,"DESCRIPTION",null,null,null,null,"AMOUNT"]
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[]
[]
[]
[]
[]
[]
[null,null,null,null,null,"TOTAL EXPENSES YOU HAVE INCURRED FOR THE COURT",{"$f":"SUM(G15:G21)","v":0}]
[null,"REIMBURSEMENT OR CONTRIBUTION:"]
[null,null,null,null,null,"Please send me a check in this amount"]
[null,null,null,null,null,"This amount is an in-kind contribution (you will receive an IRS-approved tax receipt)"]
[null,null,null,null,null,"TOTAL OF YOUR REIMBURSEMENT AND/OR CONTRIBUTION",{"$f":"SUM(G24:G25)","v":0}]
[]
[]
[]
[null,"Requestor's signature:"]
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[null,"Date submitted:"]