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Request submitted by
*
First Name
Last Name
Check Request/Reimbursement Form
Please allow up to two weeks for reimbursement. Email Tiffany Tippin at tiffanytippin@gmail.com if you need your reimbursement sooner.
Phone Number
*
E-mail
*
Your E-mail Address
Committee/Line Item Name
*
Items for Payment/Reimbursement
Please enter a line item for each receipt submitted. Include Tax if paid. No need to itemize each item purchased, just a total for each store/vendor. If your receipt includes personal items only enter the total for PTA reimbursement.
Line items
*
Date
Store/Vendor
Item(s) Description
Cost
1
2
3
4
5
6
7
8
Total Cost
*
Provide your receipt(s)
Please take a photo or upload receipt(s). Photos should only include the receipt and as little background as possible. Taking a photo works best from a mobile device. Additional Photo/Upload options will appear as needed.
Take Photo of receipt
Take Photo of receipt
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Upload receipt
Upload a File
Cancel
of
Where to send the check
Make check payable to:
*
How to deliver the check
*
LES Staff Mailbox
Mail to business
Mail to my home
Send home with my child
Pick up from Treasurer/Bookkeeper
Mailing Address
Required if delivery method is Mail to my home or Mail to business
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Teacher Information
The check will be place in the teacher's box and they will send it home with your child.
Child's Name
Teacher
Grade
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