Reimbursement / Check Request Form

Date *

Amount requested: *

USD

Check requested by: *

Your Email Address: *

Vendor / Individual To Be Paid: *

DO YOU WANT TO PICK UP THE CHECK AT THE OFFICE OR HAVE IT MAILED TO THE RECIPIENT? *Pick upMailed

Recipient Street Address

Recipient Apartment, suite, etc

Recipient City

Recipient State/Province

Recipient ZIP / Postal Code

What budget category do you want to charge this reimbursement to? If you are splitting the reimbursement among several budget categories, please indicate this by splitting the amount out among the additional rows below – use as many rows as are needed. A budget category for the amount requested must be provided. If you are unsure, please inquire with the Director of Finance and Operations.

Budget category to be used *

Reason for reimbursement? *

Amount: *

USD

Budget category to be used

Reason for reimbursement?

Amount:

USD

Budget category to be used

Reason for reimbursement?

Amount:

USD

Budget category to be used

Reason for reimbursement?

Amount:

USD

Total amount applied to budget categories:

DO YOU HAVE ANY RECEIPTS, INVOICES, OR OTHER DOCUMENTATION TO ATTACH WITH YOUR REQUEST? IF APPLICABLE, REIMBURSEMENT REQUESTS WITHOUT THE PROPER DOCUMENTATION WILL NOT BE PROCESSED.YesNo

Drag and Drop (or) Choose Files

Electronic Signature (person requesting check) *By typing my name, I hereby attest that the information recorded on this form is true and accurate to the best of my knowledge.

Name of Committee Leader or Staff Member Authorizing Reimbursement (if applicable):Leave this field blank if this is the same person requesting the reimbursement check

Email Address of Committee Leader or Staff Member Authorizing Reimbursement (if applicable):Leave this field blank if this is the same person requesting the reimbursement check