Payment Request/Reimbursement Form

Instructions:

Please fill out completely with a description of your reimbursement request and breakdown of expenses.
Attach files of all receipts and supporting documentation.
A receipt of your submitted request will be emailed to you - please keep for your records.
The treasurers will email you when your payment or reimbursement request is ready to be picked up or has been mailed.
Questions? Please contact our treasurers at hixsonmiddlepto@gmail.com

Please remember that as a tax-exempt organization we cannot reimburse sales tax, so give all vendors a copy of our sales tax exempt letter to avoid being charged sales tax when you make your purchase.

Requester Name:

Payment Method Requested*

Payee/Check made payable to:

Please include address if you would like the check to be mailed.

How should the payment be delivered?*

Total amount requested for Payment/Reimbursement:

Committee/Event*

Purpose and Expense Breakdown

Please provide a description and breakdown of purchase.

Attach Receipt/Invoice #1

Attach Receipt/Invoice #2

Attach Receipt/Invoice #3

Date Payment Needed (Please allow for 1-2 weeks)