Reimbursement Request Form

Pico Mesivta Los Angeles

Reimbursement Request Form
PLEASE READ BEFORE SUBMITTING
- Employees or volunteers, must seek pre-approval from their Department Heads, prior to making any purchases on behalf of the school.
- Employees or volunteers seeking reimbursement, must submit this form and upload all relevant receipts, prior to receiving reimbursment.
- Once submitted and approved, the request will be forwarded to Bookkeeping for reimbursement. Reimbursement payments will be issued on the 15th and last day of each month.
If you need additional information, need help completing this form or have questions about your reimbursement, please feel free to reach out to the Business Office 310-341-0186 x 1 or bookkeeper@picomesivta.org.
Employee/Volunteer Information
Name*

First NameLast Name
E-mail Address*
Your E-mail Address
Phone Number*
Please enter a valid phone number.
Purchase Information
Dynamic Dropdowns*

Item Details*

Total Cost
Please describe what these items/services were for?*
Please include as much detail and information as possible, to assure this request is processed and reimbursed in a timely fashion.
Receipt(s)/Proof of Purchase
How would you like to upload your receipts?*

Upload them from my phone or computerTake a picture directly from this form
Please upload a copy of your receipt(s) below*

Cancelof
Take Photo of your receipt*
I do not have a copy of my receipt(s) available because:*
Pre-Approval Information
This purchase was approved by?*
Approver Name*

First NameLast Name
Approver Email*
Email Address
Reimbursement Information
Do we have your direct deposit information on file?*

Yes, please use my direct deposit information on file, for my reimbursementI would like to enter or update my direct deposit information
Routing Number*
Account Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sign & Submit
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Pico Mesivta Los Angeles