Expense Reimbursement Form
Please submit this completed form with an invoice or receipts within 30 days of purchase. TAX WILL NOT BE REFUNDED – please see Mary Egan for correct form (Use Tax Exempt Certificate). Original receipts must be attached - Reimbursements cannot be made without a receipt
Date
-
Month
-
Day
Year
Today's Date
Your Name
First Name
Last Name
E-mail
Your E-mail Address
Mailing Address (for payment)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expense Details
Please complete the information below including the event (or activity) or reason for the expense along with all related expenses incurred on behalf of St Bernadette PTU. Before submitting, be sure to attach receipts for all expenses.
Event / Activity / Reason
Were these expenses approved by the chairperson?
Yes
No
Not sure
Chair Person Name
First Name
Last Name
List all of your expenses below:
*
Purchase Date
Purchase Description
Purchased From
Cost ($)
1
2
3
4
5
6
7
8
9
10
11
12
Total Cost
Receipt
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of
Notes
Provide any additional notes that may help in processing your reimbursement
For Treasurer Use Only
Date Paid
Check #
Comments
Treasurer Signature
Submit
Should be Empty: