REIMBURSEMENT REQUEST FORM
Fill out the form below completely. All receipts should be attached to the form.
Request Date
*
-
Month
-
Day
Year
Date
Budget Category
*
Submitted by (must be submitted by a board member)
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Payable to:
*
First Name
Last Name
Preferred Payment Method:
*
Check Request
PayPal
Zelle
ACH (Automated Clearing House) Transfers
PayPal Email
Zelle Account (Phone Number or Email address)
ACH Payment Information
Rows
Payee's Bank Information
Bank Name:
Routing Number:
Account Number:
Account Type:
Email for Confirmation:
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Rows
Description of Purchase
Amount
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total Reimbursement Amount:
*
Upload Invoice(s) and/or Receipt(s)
*
Browse Files
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