DDWSF Expense Reimbursement Request Form

Please complete with the details of up to 4 expenses for reimbursement. For additional items, please submit an additional form.

Item 1: Please attach original receipts

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Item 2: Please attach original receipts

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Item 3: Please attach original receipts

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Item 4: Please attach original receipts

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Subtotal
Advance Payment Towards Expenses (if applicable)
Check one to elect to make this expense a contribution/donation to DDWSF:

I would like to contribute the total amount to DDWSFI would like to make a contribution in the amount specified below to DDWSF.
I would like to make a contribution in the following amount:
An acknowledgement letter will be sent if your donation is over $250.
Total Reimbursement Amount Requested (please calculate as follows: Subtotal - Advance Payment Toward Expenses - Contribution)
How would you like reimbursed monies sent to you:
If you selected "Check" please enter the name of the "Payable to" party below.
If you selected "Zelle" please enter the associated email or phone number below.
example@example.com
By signing below, I acknowledge that I have received and consent to uphold the policies as put forth in the DDWSF Financial Control Policies and Procedures:
Signature

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Should be Empty: