Atkinson Elementary Pta Check/reimbursement Request Form

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ATTACH
RECEIPT(S)
IN BACK
ATKINSON ELEMENTARY PTA
C
/R
R
F
HECK
EIMBURSEMENT
EQUEST
ORM
~ Please Print Clearly ~
Requested by:
Date:
Phone #:
Amount of Reimbursement:
$
Email:
1. Payee Information (if different from above)
Name: _______________________________________
Phone #: _____________________________________
Email: _______________________________________
2. Delivery Options
Leave check in:  PTA Treasurer’s Box
 Teacher/Staff Box
 Home/Business
Send check to:
______________________________________________________________________________
Street Address
City
State
Zip
3. Expenditure Information
P TA Program/Activity/Event: _____________________________________________________
Expenditure Description: __________________________________________________________
______________________________________________________________________________
Chair Approval/Signature (required for standing committees): ______________________________
If OLG, specify category designation: __________________________________________
Reimbursement checks related to an approved PTA activity will be cut and distributed within three weeks of receipt.
T
U
O
REASURER
SE
NLY
Check #:
________________
Line item:
______________________________
Date Paid:
________________
Comments: ______________________________
Date Sent:
________________
________________________________________
Date cleared: _______________
________________________________________
Initials:
________________
________________________________________

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Parent category: Business
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