District Reimburse/Payment Request

District Expense Reimbursement or Payment Request Form

Please fill out the form below to request reimbursement or vendor payment for all Club or District expenses. This request requires approval from District Governor or designate before payment from Treasurer. Any questions please contact Paul Mangels (rotarytreasurer7980@gmail.com)
Full Name of Payee

First NameLast Name
Payee Company (if applicable)
Email Address*
example@example.com
Phone Number*
District, Club, AG, or choose Vendor
Mailing Address for Payee*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Purpose of Expenditure *
Please provide a brief description of the event, program, or meeting

Expense Details (please upload receipts to expedite the process)*

Total Reimbursement Amount (USD)
If expenses exceed five lines, create and upload an identical Excel spreadsheet.
Upload Receipts or Documents

Receipts, pdf, xlsx, docx, etc
Cancelof
Signature* Signature of person submitting request (can be typed or drawn)
Should be Empty:

District Expense Reimbursement or Payment Request Form