Staff Reimbursement Request

Bayard Rustin Elementary School PTA

Staff Reimbursement Request
School staff who are PTA members can use this form to request reimbursement for supplies they have personally purchased for school/student use (up to $100/year)
Date of Request

MonthDayYear
Date
Check Requested By*

First NameLast Name
Email*
example@example.com
Check Payable To*

First NameLast Name
Mailing Address (If you wish to receive check by mail)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount*
Amount of reimbursement requested

Itemization of Expenses*

Additional Notes
Upload Receipts*

Browse Files
Attach pictures of receipts here - maximum size 10MB - accepted formats pdf, doc, docx, html, zip, jpg, jpeg, png, gif Cancelof
By checking this box, I attest that I in fact made the above listed expenditures on behalf of students/the school and that my purchases become property of the school after the PTA has reimbursed me for them.
FOR SCHOOL OFFICERS

Signature/Approval:
Name of Approver
Should be Empty:

Bayard Rustin Elementary School PTA