REIMBURSEMENT REQUEST FORM

REIMBURSEMENT REQUEST FORM
Use this form to submit a reimbursement request associated with a foundation-managed grant or fund. Before the foundation can process your request and release payment, the grant must be approved and all information below completed. Receipts/invoices or back up documentation must be included for payment to be processed (see Step 8 below).

For questions, please contact Dana Floro c_dfloro@smcgov.org or call the Foundation at (650) 573-2655 (Monday-Friday, 9am-4pm).
1. TODAY'S DATE*

MonthDayYear
2. REQUESTER*

First NameLast Name
DEPARTMENT*
EMAIL*
MOBILE NUMBER*
PAYEE*
Who should we make the check out to?
3. AMOUNT *
4. We prefer that checks be picked up from the Foundation office. If you'd like your check mailed instead, please provide your mailing address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. DEPARTMENT*
6. ORG #*
You must include the appropriate Org #. Please do not fill in "I don't know".
7. TITLE OF APPROVED GRANT ASSOCIATED WITH THIS PAYMENT*
8. PLEASE UPLOAD BACK-UP DOCUMENTATION (i.e., expense report, receipts, etc.) or send a copy to c_dfloro@smcgov.org.

Cancelof
FOUNDATION USE ONLY
Approved By
Approval Date
Payee
Reference/Project #
Fund
Notes
Amount
Check #
www.smchf.org

222 West 39th Avenue San Mateo, CA 94403 (650) 573-2655 office (650) 573-3447 fax
Should be Empty:

FOUNDATION USE ONLY