PTSA Reimbursement & Payment Form

Reimbursement or Payment Form
Submitter's Name*

First NameLast Name
E-mail*
Your E-mail Address
Phone Number
Format: (000) 000-0000.
Program to be Charged*

PTSA GeneralLive Events/AuctionSenior SPREEPTSA Grant AwardsTeacher/Staff AppreciationRaise the PaddleOther
Grant Description
Enter in the SHORT description of your grant.
Grant Season
Enter in the SHORT description of your grant.

Expense List*

Total Cost
Receipt*

Cancelof
How would you like to receive your funds?*

Electronic/ACH TransferDirect Payment - Check (Mailed)Pre-Paid via BHS PTSA Debit Card
Is this payment urgent?

YesNo
If urgent, please provide details. *
Please explain the reasoning for this request to be considered urgent.Invoice due date, payment required in-person for event, etc.
Link to pay:
Make Payment To:
Company/Person Direct Check Payment will be written out to
Address to Mail Check

Street Address

Street Address Line 2

CityState

Zip Code
Notes
If the information above is incorrect and a stop payment is required, $30 will be deducted from the amount issued for reimbursement.*

I certify that all information entered above is correct and true.
Should be Empty:

Reimbursement or Payment Form