PAYMENT AUTHORIZATION/REQUEST FOR REIMBURSEMENT
ATTACH ALL RECEIPTS TO THIS EXPENSE STATEMENT
PTA Member:
First Name
Last Name
Name of Payee
PTA Position
Type of Reimbursement
Teacher - Class Fund
Staff Reimbursement
PTA Program or Event
PTA - Non Program/Event
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Email of VP/Chairman of Program/Event
example@example.com
Expenditure was for
*
List Expenditures (if you have more than 4 line items, you can summarize - just be sure to attach the detailed receipts)
*
Description
Amount (0.00)
1
2
3
4
Total Expense
Total Requested from Above
Advance Received (if any)
Not Claimed - Donate to PTA
Advance Received (form)
PTA Donation (form)
Reimbursement Claimed:
File Upload
*
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of
Requestor's Signature
*
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit for Approval
VP Chairman for Program/Event Approval
VP Program/Event Signature
*
VP Program/Event Approval Date
/
Month
/
Day
Year
Date
Submit Program Approval
Treasurer Information
Treasurer Use:
Membership-Approved Activity
Funds released by membership
Executive Board-approved expenditure
Expense Category
Check Number
Amount Advanced
Expenses
Amount Owed or Due
Check Stub
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of
Treasurer Submit Date
/
Month
/
Day
Year
Date
Submit Treasurer Information
Secretary Signature
Date Approved in Minutes
/
Month
/
Day
Year
Date
Secretary's Signature
*
Secretary Approval Date
/
Month
/
Day
Year
Date
Submit Secretary Signature
President Approval
President's Signature
Cleared Check Copy
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of
President Sign Date
/
Month
/
Day
Year
Date
Submit President's Signature
Status
GDrive Date
-
Year
-
Month
Day
Date
GDrive Folder Name
Form Status
Please Select
Submitted
Waiting on VP Program/Event
Waiting on Treasurer
Waiting on Secretary
Waiting on President
Approved
Treasurer Email
*
example@example.com
Secretary Email
*
example@example.com
President Email
*
Should be Empty: