FOUNDATION REIMBURSEMENT REQUEST FORM

FOUNDATION REIMBURSEMENT REQUEST FORM
Notice: The Foundation will not be reviewing reimbursement requests from April 24 through May 13. You're still welcome to submit your request, and it will be processed in the order it's received.

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*
Format: (000) 000-0000.
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 REIMBURSEMENT REQUEST FORM

FOUNDATION USE ONLY