To request a reimbursement check, please complete this form and submit to CHARITYSMITH. Please include an accurate description (i.e. room rental for April fundraiser) and a receipt for each expense. Contact [email protected] with any questions. DOWNLOAD FORM HERE

Date:

Memorial Fund Name:

Expenses to be Reimbursed (Please attach a photocopy of the receipt for each expense):

Expense 1

Date:

Vendor:
Purpose:
Amount:
Attachment:

Expense 2

Date:

Vendor:
Purpose:
Amount:
Attachment:

Expense 3

Date:

Vendor:
Purpose:
Amount:
Attachment:

Expense 4

Date:

Vendor:
Purpose:
Amount:
Attachment:

Expense 5

Date:

Vendor:
Purpose:
Amount:
Attachment:

Expense 6

Date:

Vendor:
Purpose:
Amount:
Attachment:

Expense 7

Date:

Vendor:
Purpose:
Amount:
Attachment:

Check Payable To:

Address:

Memorial Fund Administrator Approval:

Name:

Email:

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