Reimbursement Request Form

Reimbursement Request Form

SCV AFG Intergroup Inc.
You will be required to fill out this reimbursement request form completely - have all your documentation handy when you begin to fill out this form.

You will be able to upload all original bills, invoices, receipts, proof of payment etc. directly into this form.

Submit to an Officer for approval and payment.
Date of Request:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Amount of Reimbursement:
Payable to:
Address of person receiving payment:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of requestor:
Please enter a valid phone number.Format: (000) 000-0000.
Description of Expense:
Expense will be allocated to one following areas of the organization:
Please explain which officer or coordinator position and any other information that may be needed to approve this request:
Is Zelle an acceptable form of payment? We will make every effort to make payments via Zelle before writing a check.
If yes to Zelle: Requestors registered email address with Zelle:
example@example.com
If yes to Zelle: Requestors registered mobile number with Zelle:
Please enter a valid phone number.Format: (000) 000-0000.
Requested by:
Upload all original bills, invoices, receipts, proof of payment etc. in this space

Cancelof
FOR SCV AFG Officer only: Who approved this Reimbursement Form:
FOR SCV AFG Officer use only: Payment issued by:
If Check is required - Check #:
Should be Empty: