Arizona ESA Itemized Invoice Request
Request an unpaid, itemized invoice for ClassWallet submission—share student and learning resource details, and confirm you’re not submitting any login, payment, or identity information.
Parent/Account-Holder Full Name
*
First Name
Last Name
Contact Email
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Student Full Name (as it should appear on the invoice)
*
First Name
Last Name
Student Age
*
Student Grade Level (if applicable)
Please Select
Pre-K
K
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Not Applicable
Requested Learning Resources (list each product name or Luminara Prep product URL, and the quantity requested for each item)
*
Do you need help choosing learning resources?
*
Yes
No
Do you need the Arizona ESA Documentation Packet?
*
Yes
No
Notes or Questions
NOTICE:
Do
NOT
submit ESA login information, ESA account numbers, Social Security numbers, medical records, payment-card details, passwords, or identity documents. This form is for requesting an unpaid invoice only.
Example: a $1,000.00 product/service subtotal requires a $20.41 processing-fee line and a $1,020.41 invoice total under the current 2% ClassWallet fee.
I understand that my ESA/ClassWallet account is managed by the account holder. Luminara Prep will never ask for or access my ESA/ClassWallet login credentials, password, payment-card information, or other account-access information.
*
I understand that an invoice request is not an approval or a completed ESA purchase and Luminara Prep will fulfill an ESA order only after the applicable approval/payment confirmation.
*
Request Invoice
Should be Empty: