Reimbursement/Check Request

This form is to be used by volunteers, teachers, staff and administration when requesting reimbursement for budgeted expenditures and approved funding requests.

Requester's Name*
Prefix First Last
Email*
Mobile Phone
Payee Name:*
This is the name that will be printed on the check.
Payee Type*
Please select the type that most appropriately applies to the Payee.
Mailing Address
This is the address the check will be mailed to.

Street Address Address Line 2 City State ZIP Code
Reimbursement Information
Title for this Request*
Please give a short name for the request.
Reimbursement Amount*
Combine multiple receipt values into one check payment amount.
Description*
Please describe what the reimbursement is for. Include a summary of the items purchased (do not list each line item).
Upload Receipt(s)
For simplicity, you may take pictures of the receipt(s) and upload.
Drop files here or