Reimbursement

Reimbursement

Complete this form to request a reimbursement check for Henry's Home expenses.
Date*

MonthDayYear
Type of Expense
Submitted By*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Make Check Payable To:*
Check Recipient Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Description and cost of item(s) or service(s) purchased

Total Requested Reimbursement Amount
I will provide physical receipts instead of uploading*

YesNo
Upload receipt (receipts required for reimbursement)

Cancelof
Is this for a Fundraising event*

YesNo
Which fundraising event
Once submitted, your request will be reviewed for approval prior to reimbursement. Thank you for your support of Henry's Home!

We are a tax-exempt organization, as described in Section 501c3 of the Internal Revenue Code.
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