BNGSA Payment & Reimbursement Form
PO Box 673 - Bloomington, IL 61702
General Information
Get started by entering an individual or an organization/business to reimburse/pay. Based on selections, you might be asked for additional information. Separate forms should be submitted for each payee. See the BNGSA Treasurer's manual for additional guidance.
Name of Person to Reimburse
First Name
Last Name
** or **
Name of Org/Business to Pay
Date Payment Needed
*
-
Month
-
Day
Year
Select Date
Payment/Reimbursement Method
*
Please Select
Check
PayPal
Website
Other
Selection prompts for additional info
Payment Mailing Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Enter PayPal Email Address
*
example@example.com
Website or Shopping Cart Address
*
NEVER send a logon and password to a website here. Text BNGSA Treasurer logon info using two different texts.
Additional instructions
Enter additional instructions. NEVER send a logon and password to a website.
Expense Details
Please be as detailed as possible and attach DETAILED receipts supporting all requests. A receipt with no detail (e.g. credit card receipt) is not a valid proof of expenditure. You can paste links to online items (e.g. Amazon) and tournament registration information/carts.
Select BNGSA budget to charge
*
Please Select
Budget 4 - Specific Travel Team
Budget 2 - In-Town Program
Budget 3 - Travel Program
Budget 1 - Admin
Travel Teams: Select Budget 4 to get a team list.
Select BNGSA Travel Team
*
Please Select
Angels-Slaughter (2035)
Angels-Egenes/Stenger (2034)
Angels-Wiedman (2033)
Angels-Purcell (2032)
Angels- Benedict (2031)
Angels- Vogelsang (2030)
Angels- Krones (2028)
Angels- Wait (2027)
Angels- McGrath (2026)
Guardians- Tanner
Guardians-Bunn
Guardians- Post
Venom- Kopp
Shock- Boyd
Select the team budget to charge for the expense or reimbursement.
Purchase/Invoice Date #1
-
Month
-
Day
Year
Select Date
Amount #1
Enter amount in dollars & cents
Expense #1 Description
200 Character Limit
Upload photo receipt for item 1
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Purchase/Invoice Date #2
-
Month
-
Day
Year
Select Date
Amount #2
Enter amount in dollars & cents
Expense #2 Description
200 Character Limit
Upload photo of receipt for item 2
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Purchase/Invoice Date #3
-
Month
-
Day
Year
Select Date
Amount #3
Enter amount in dollars & cents
Expense #3 Description
200 Character Limit
Upload photo of receipt for item 3
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Purchase/Invoice Date #4
-
Month
-
Day
Year
Select Date
Amount #4
Enter amount in dollars & cents
Expense #4 Description
200 Character Limit
Upload photo of receipt for item 4
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Purchase/invoice Date #5
-
Month
-
Day
Year
Select Date
Amount #5
Enter amount in dollars & cents
Expense #5 Description
200 Character Limit
Upload photo of receipt for item 5
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Calculated Amount to Pay or Reimburse
Send Confirmation Email to
*
example@example.com
Expense Sheet Certification
*
I certify that all information entered above is valid and true. I also certify I have attached the appropriate detailed documentation to support the payment/reimbursement I am requesting.
Your Name
*
First Name
Last Name
Your Signature
*
Submit Form
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