FOUNDATION REIMBURSEMENT REQUEST FORM

FOUNDATION REIMBURSEMENT REQUEST FORM
Use this form to submit a reimbursement request associated with a Foundation-managed grant or fund. Before the Foundation can review your request and release payment, all information below must be completed and the grant must be approved.

Receipts/invoices and/or back up documentation must be included for payment to be processed (see Step 7 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
ORG #
You must include the appropriate Org #. Please do not fill in "I don't know".
EMAIL
MOBILE NUMBER
Format: (000) 000-0000.
3. AMOUNT OF REIMBURSEMENT
The final amount of the reimbursement cannot exceed the approved grant or budget allotment defined by the project owner.
4. PAYEE
Who should we make the check out to?
5. We prefer that checks be picked up from the Foundation office. If you'd like the check mailed, please provide the mailing address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. TITLE OF APPROVED GRANT ASSOCIATED WITH THIS PAYMENT
7. PLEASE UPLOAD BACK-UP DOCUMENTATION (i.e., expense report, receipts, etc.) or send a copy to c_dfloro@smcgov.org.

Cancelof
FOUNDATION USE ONLY

Do not complete this section
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 REIMBURSEMENT REQUEST FORM

FOUNDATION USE ONLY