PTSA Online Reimbursement and Payment Request form

Instructions:

Fill out completely with description of reimbursement and attach original receipt(s)
A receipt of your submitted request will be emailed to you (keep for your records)
Receipts or invoice required for all reimbursements
Questions? Please e-mail treasurer@mihsptsa.org

Reimbursement Information

Event/Activity/Job:

Check made payable to:

Total Amount Requested for Reimbursement/Payment:

If a receipt is not attached, we are unable to reimburse the total amount requested.

Requested by:

Address:

Phone:

Date of Request:

Expense 1 - Date:

Expense 1 - Item Purchased

Expense 1 - Amount

Attach Receipt/Invoice #1

Expense 2 - Date:

Expense 2 - Item Purchased

Expense 2 - Amount

Attach Receipt/Invoice #2

Expense 3 - Date:

Expense 3 - Item Purchased

Expense 3 - Amount

Attach Receipt/Invoice #3

Expense 4 - Date:

Expense 4 - Item Purchased

Expense 4 - Amount

Attach Receipt/Invoice #4

Expense 5 - Date:

Expense 5 - Item Purchased

Expense 5 - Amount

Attach Receipt/Invoice #5

Approved By (VP/Chairperson):

Date Check Issued:

Check Number:

Account Name:

Notes:

QB Entry Date: