NSA Michigan Financial Disbursement and Reporting Form
What kind of financial request/report is this?
*
Member Reimbursement Request
Vendor Payment Request
Debit Card Use Report
Vendor Auto Pay Receipt
Refund Request
Other
Submitter Name
*
First Name
Last Name
Submitter Phone Number
*
Format: (000) 000-0000.
Submitter E-mail
*
Your E-mail Address
Payee Name (if different than submitter)
Preferred Payment Method
Please Select
Check
PayPal
Online Payment Link
Other
Only complete this field for payment requests
Remittance Address
Provide mailing address for check, email address for PayPal, email address and phone number for Zelle, or link for online payment. No address needs to be provided for debit card reports
Payment Date
*
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Month
-
Day
Year
For payment requests, day that payment is due. For debit card reports, day that payment was made.
Expense Detail
Expenses List
*
Rows
Purchase Date
Budget Category
Product/Service Description
Cost
Payee
1
2
3
4
5
Total Cost ($)
*
Please attach receipt or invoice here
*
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