Sample - Check Request/Reimbursement Request Form (simple)

Instructions:

Please fill out completely with description of reimbursement and breakdown of expenses.
Attach up to 3 files/pictures/scans of all receipts and supporting documentation.
A receipt of your submitted request will be e-mailed to you (please keep for your records).
The treasurer will e-mail you when your check is ready to be picked or has been mailed to you.
Questions? Please e-mail our treasurer at Treasurer@mesaviewptso.com.

Date

Date of Request

Name of Person Requesting

Check made payable to:

Should the check be mailed directly to the vendor/payee or dropped off at school?*

Mailing Address

If check is to be mailed, include mailing address

Phone

List Phone Number

Email Address

List email address

Total Amount Requested for Reimbursement/Payment:

Committee/Event*

Description/Purpose:

Attach Receipt/Invoice #1

Attach Receipt/Invoice #2

Attach Receipt/Invoice #3

Date Check Needed (please allow at least 1-2 weeks if possible):