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Madison County Fiscal Court
Request for Purchase
This document needs to be completed prior to purchase of any items until a new Purchase Order system is put in place
by the Finance Office. Individuals requesting items should complete and have their department head sign off. The
Department Head should send to Francette (preferably electronically) and once approved, the item may be purchased.
At the point of purchase, the receipt and request for purchase form should be attached to the Purchase Order and
submitted to the Finance Office for payment.
Department: __________________________________________________________________________
Staff Member Requesting: _______________________________________________________________
Item(s) Requested:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Purchasing from:____________________________________________________________________________________
Line Item: _________________________________________________________________________________________
Estimated Cost:_____________________________________________________________________________________
What is this item being used for?
Are funds available in the ’15-’16 budget? ____ Yes
If no funds are available in ‘15 – ’16 budget:
Have funds already been transferred? ____ Yes
Do funds need to be transferred?
____ Yes
___No
____ No
____ No
Explanation:
Signature of Department Head:___________________________________________________________
Signature of Judge Executive: _____________________________________________________________