Check Request/Reimbursement Request Form '26-'27

Instructions:

Please fill out completely with description of reimbursement and breakdown of expenses.
Checks will be sent out 3 times a month. Please allow 10 days for your check to be sent to you before inquiring about its whereabouts.
Attach a file/picture/scan of each receipt and/or supporting documentation.
If a check is to be sent directly to a vendor, please make sure the address/phone # are included.
A receipt of your submitted request will be e-mailed to you (please keep for your records).
Questions? Please e-mail our treasurer at moultrietreasurer@gmail.com.

Make check(s) payable to:

Grand total amount for reimbursement:

Would you like to pick up the check or have it mailed to your home (the address on your contact record)?*

Vendor

Expense category*

Amount