Reimbursement Request Form

Reimbursement Request Form
Reimbursments will only be processed for approved Leadership initiatives expenses.

Completion of this form does not guarantee reimbursement. If you have any questions or concerns, please reach out to Blake Spreeman, via email at Bspreeman@lichange.org or phone at (424) 398 -9703.
Name

First NameLast Name
Email
example@example.com
Phone Number
What was the expense?
Please provide brief details for the purchase, and why you had to use your card.
Reimbursement Amount
Please upload Receipt/Proof of Purchase

Cancelof
Reimbursement Method Preference
Zelle Phone Number / Email
Other:
Paypal Email
CashApp UserName
Venmo Username
Should be Empty: