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This form can be used to upload up to 20 documents containing receipts, invoices or other backup documentation for your check request. Make sure your images are complete and fully legible before uploading them. UCP cannot reimburse items that are incomplete or illegible. All requests are subject to approval by the Tennessee Council on Developmental Disabilities.

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* 1. This payment request is for

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* 2. Name or Description of Approved Conference or Funded Activity

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* 3. Person entering information/submitting this check request

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* 4. I Am

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* 5. Payee Name (Name on Check) and Address

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* 6. Total $ Amount this Check/Reimbursement Request (amount and backup documentation must reconcile to the total of each item submitted in the next section).

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