Head of the Lakes
Organ Transplant Group
Reimbursement form

Date of Request Authorized Signature

Date Check Needed Amount of Check

Payable to:

Address:

Description of Expense:

Date Expense Detail Amount

Please fill out check request and mail to: Traci Marciniak, Program Director

Miller-Dwan Foundation

502 E. Second Street

Duluth, MN 55805

(218) 786-2823

For office use only:

Designated Fund Award #: