Facility Grant Reimbursement Form

FACILITY FUND GRANT REIMBURSEMENT

Wisconsin Swimming, Inc.
INSTRUCTIONS: Recipients of Wisconsin Swimming Inc. Facility Fund Grant Awards must complete the below form for reimbursement of expenses incurred for the purchases approved by the WSI Facility Fund Grant Committee. Failure to provide the requested information, including proof of purchase may forfeit the award. Please direct any questions to the Wisconsin Swimming Tech Planning Chairperson or the Finance Manager.
CLUB NAME
CLUB CODE
CONTACT PERSON
EMAIL
example@example.com
PHONE
GRANT REIMBURSEMENT INFORMATION
Grant amount awarded by WSI
Date of Grant

MonthDayYear
Date
Description of the item(s) purchased
Date of purchase

MonthDayYear
Date
TOTAL REIMBURSEMENT REQUESTED
Must attach proof of purchase. Amount not to exceed grant amount awarded.*

May attach more than 1 file
Cancelof
Send reimbursement to:

Street Address

CityState

Zip Code
Signature
Date

MonthDayYear
Date
Should be Empty:

FACILITY FUND GRANT REIMBURSEMENT