CHECK REQUEST: PAYMENT AUTHORIZATION/REQUEST FOR REIMBURSEMENT

Name of Requester *

Name of Payee (if different from requester)

PTA Position

Date of Reimbursement Request * +

Street Address *

City *

Zip Code *

Telephone

Email Address of requester: *

Note: If you have more than 5 expenses to reimburse, please use the EXPENSE REIMBURSEMENT ADDENDUM.

(Click on make a copy and fill up the addendum. Once complete, save the addenfum as PDF and attach in the file upload section.)

Important: Remember to upload your addendum (if applicable) and all invoices/receipts in the file upload section when submitting your reimbursement.

Name of PTA Project or Program the Expenditure was for: *

If you have more than 5 receipts please use the expense reimbursement addendum.

I am using the expense reimbursement addendum. The total reimbursement amount is listed in the "Expense #1". A copy of the Addendum is uploaded in the "File Upload" section.

List Expense #1 *

Expense #1 Amount: *

Budget Category #1

List Expense #2

Expense #2 Amount:

Budget Category #2

List Expense #3

Expense #3 Amount:

Budget Category #3

List Expense #4

Expense #4 Amount:

Budget Category #4

List Expense #5

Expense #5 Amount:

Budget Category #5

Current Total:

$0.00

Total Amount Claimed from Above: $ *

Minus Advance Received: $

Minus Amount Not Claimed (Donate to PTA) $

Total Amount Claimed From Above

0.00

Total Reimbursement Claimed: $ *

Refund to PTA (Use Refund to PTA Submission Form)$

Signature of Payee / Requestor *

clear

Upload Addendum/Invoice/Receipt File #1 (up to 10 attachments) *

Upload Invoice/Receipt File #2 (up to 10 attachments)

Upload Invoice/Receipt File #3 (up to 10 attachments)

Upload Invoice/Receipt File #4 (up to 10 attachments)

Upload Invoice/Receipt File #5 (up to 10 attachments)

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