Back Country Horsemen of Idaho Foundation
PO Box 498, Newport, WA 99156
Exempt Number 82-0510506
Request for Reimbursement
Chapter Name:___________________________________________________________
Program:________________________________________________________________
Amount Requested:_______________________________________________________
Check Payable to:________________________________________________________
Address:________________________________________________________________
City:___________________________State:_____________________Zip:___________
___________________________________ _________________
Authorized Disbursement Agent Date
Back Country Horsemen of Idaho Foundation
PO Box 498, Newport, WA 99156
Exempt Number 82-0510506
Request for Reimbursement
Chapter Name:___________________________________________________________
Program:________________________________________________________________
Amount Requested:________________________________________________________
Check Payable to:_________________________________________________________
Address:________________________________________________________________
City:____________________________State:____________________Zip____________
____________________________________ _________________
Authorized Disbursement Agent Date