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 the 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.

After submission, the Parish Administrator will confirm authorization from the appropriate Vestry member before the check is issued.
Submitted by

First NameLast Name
Date Submitted

MonthDayYear
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:
Upload a Copy of Receipt

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