Payouts & Reimbursement Requests

Date on Receipt*

MonthDayYear
Date
Store/Company Name*
What company was this purchase made from? i.e. Target, HEB, Amazon, etc.
Receipt Transaction Number *
If receipt does not have a transaction number, please create one using the following structure: "YearMoDay-ReceiptAmount" i.e. For a receipt from 08/31/2024 for $48.32, please make the transaction number: 20240831-4832
Reimbursement Amount*
Is this amount less or more than $100?*

Less than $100More than $100
Was this purchase a recurring expense (flowers, birthdays, etc.) or a one-time expense?*

Recurring ExpenseOne-Time Expense
Upload Receipt (Photo or PDF)*

Cancelof
Please share in detail what this purchase was for: *

I, {name}, understand that this reimbursement is pending approval of the Chick-fil-A Georgetown leadership team. If approved, funds less than $100 will be reimbursed as a payout with cash through a register with Director approval. Funds more than $100 will be processed as a reimbursement on your paycheck. Please note that paycheck reimbursements may take up to two weeks depending on where we are in the the pay period.

I also certify that this transaction occured in the current month.
Signature*

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Today's Date*

MonthDayYear
Date
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