Check Request and Reimbursement Form REVISED 2022

Check Request and Reimbursement Form

Instructions: Fill out the form below and attach receipts/documentation. Submit them to parish administrator. Please note: It may take up to 30 days to process and issue checks/reimbursements. No reimbursements will be issued without receipts attached. No payments will be issued without supporting documentation.
Submitted by *

First Name Last Name
Date Submitted *

Month Day Year
Date
Phone Number

Area Code Phone Number
ACCOUNT to be Charged: *
Program/Purpose *
Make check payable to:
Street Address:
City, State, Zip:
Amount $ *
Please enter a number without a dollar sign.
For Reimbursements:

Yes, in lieu of a check, please apply the above amount as an in-kind/non-cash donation to the account listed above. I understand that this amount will be included on my end-of-year contribution statement for tax purposes.
Upload a Copy of Receipt

Upload a File
jpg, pdf, png, etc Cancel of
For Office Use:
ACCOUNT: Designated _____ General _____
CHECK NUMBER ________ DATE PAID ____________
Should be Empty: