PTA Payment Authorization/Reimbursement Form

Instructions:

1. Fill out completely with the description of reimbursement and breakdown of expenses by budget category (missing info will delay payment).

2. Attach copies of all receipts.
3. Specify if the check should be placed in office file folder or mailed to yourself/vendor.
4. A receipt of your submitted request will be emailed to you (to keep for your records).

Questions: Email mcauliffetreasurer@yahoo.com

Item Description Price Qty

Reimbursement Information

Select Type*

Check Payable To:

Should check be placed in your folder or mailed?

If check is to be mailed, provide the address.

EVENT/COMMITTEE/DEPARTMENT for expense-Submit separate forms for each*

Other (please list budget line)

EXPENSES for Reimbursement or Check Request

How many items(expenses) are you listing for this Event more

$0.00

#1	Expense Amount Expense Description Vendor/Store Name for Expense	copy
#2	Expense Amount Expense Description Vendor/Store Name for Expense
#3	Expense Amount Expense Description Vendor/Store Name for Expense
#4	Expense Amount Expense Description Vendor/Store Name for Expense
#5	Expense Amount Expense Description Vendor/Store Name for Expense
#6	Expense Amount Expense Description Vendor/Store Name for Expense
#7	Expense Amount Expense Description Vendor/Store Name for Expense
#8	Expense Amount Expense Description Vendor/Store Name for Expense
#9	Expense Amount Expense Description Vendor/Store Name for Expense

Attach Receipts

Please attach one file with copies of all receipts

Attach receipt

Attach Receipts

Please attach one file with copies of all receipts

Your reimbursement will not be dispersed until ALL RECEIPTS are submited electronically or physically dropped off in the school office in the PTA REIMBURSMENT basket. NOTE*CHECK MAY BE DELAYED IF receipts are dropped off and not uploaded**

Receipt or Invoice Submitted?*

Reason for not submitting Receipts

Treasurer's Notes

(to be completed by the Treasurer)

Date Check Issued

Total Amount For Reimbursement:

Check Number:

Notes

PTA Payment Authorization/Reimbursement Form

Reimbursement Information

Treasurer's Notes

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