SU72 Expense Reimbursement/SU Check Request Form

SU72 Expense Reimbursement/SU Check Request Form

Use form to request reimbursement or schedule payment directly to a vendor from GSHNJ Service Unit 72.
Name of Submitter*

First NameLast Name
SU Position of Submitter*
Submitter email address*
example@example.com
Forms submitted by a Volunteer must be approved by the appropriate Committee Chair prior to review by the SU Manager for approval. Forms submitted by Committee Chairs only require review by the SU Manager for approval. Enter the appropriate SU Committee information below.
Enter applicable SU Committee*
This request for an expense related to:*

Fee-based event (budget submitted)Non-fee based expense (annual approval)Credit card refund (automated via payment gateway)
Enter reason for credit card refund:
Payment Gateway
Stripe sub-account
Attach a .pdf of the credit card transaction(s) from the payment gateway (from the Stripe sub-account developer access).

Browse Files

Cancelof
Event Name*
Council Reporting Category*
Purpose of Expenditure*
Upload .pdf file(s) of all receipts associated with this payment request. *

Browse Files
Limit 10 files. Cancelof
Do not include sales tax which could have been avoided with the use of the ST-9 form in the “Amount Requested” field.
Amount Requested*
This spreadsheet is to assist you in adding up your reimbursed totals and is NOT required. Do not include $ in the amount column.
Payee

First NameLast Name
Business Name (if payee is business)
Email Address of Payee:*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Delivery*
Submitter is responsible for make specific arrangements with the SU Treasurer if Payment Delivery of "Other" is selected.
Name to contact for Debit Card

First NameLast Name
Phone to call for Debit Card

Area CodePhone Number
Date request submitted*

MonthDayYear
mm/dd/yyyy
Additional comments
****SERVICE UNIT TEAM ONLY****
COMMITTEE CHAIR ONLY
Committee Chair?
Committee Chair Name*

First NameLast Name
Date of Committee Chair Decision*

MonthDayYear
mm/dd/yyyy
Committee Chair Signature
Committee Chair Approval Status:*
Committee Chair Comments (required if denied)
SU MANAGER ONLY
SU Manager?
SU Manager Name*

First NameLast Name
Date of SU Manager Decision*

MonthDayYear
mm/dd/yyyy
SU Manager Approval Status
SU - Manager Comments (Required if Denied)
Confirm credit card refund total, if applicable
SU Manager Signature
Girl Scout Year
Should be Empty: