PAYMENT AND/OR REIMBURSEMENT APPROVAL REQUEST rev. 9/2024

PAYMENT AND/OR REIMBURSEMENT APPROVAL REQUEST

Revised 9-2024
Amount in US$*
BOTH $ AND CENTS
Description: Please be as specific as possible.*
Reimbursements for future events will be processed after the event occurs.
Submitted for payment by:*
Name
Submitter Email:*
example@example.com
Submitter's Phone*
YesNo
Remit Payment To:*
Name
Recipient's Email*
example@example.com
Recipient's Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Recipient's Phone*
Date Expense was Incurred: *

MonthDayYear
Date
Date Submitted for Payment:*

MonthDayYear
Date
Lookup the Expense Account # Here

Enter Expense Account # & Amount*

For the Expense Chart

of Accounts, click HERE.
Total Amount - $
Calculated Field
REQUEST CANNOT BE SUBMITTED UNLESS THE TOTAL MATCHES THE REQUEST , OR IF THE LINE ITEM HAS NOT BEEN FILLED.
This hidden field tests if they've inserted a line item, and hides the Submit button if they haven't.
Attach invoices / receipts substantiating expenditure(s)

Browse Files

Cancelof
SPECIAL INSTRUCTIONS - NOTES - COMMENTS - PAYMENTS WILL BE BY CHECK UNLESS OTHER ARRANGEMENTS ARE REQUESTED.*
Ex: wire transfer required, Global Grant Scholarship payment from dedicated account, special payee instructions, etc.
Signature of Submitter:*

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