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 NameLast Name

Date Submitted*

Date

Phone Number

Area CodePhone 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

For Office Use:
ACCOUNT: Designated _____ General _____
CHECK NUMBER ________ DATE PAID ____________