CHESS Reimbursement/ Refund Form

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1. *

List the Activity for this Reimbursement/ Refund:  (select)
 


Use your Ctrl & Shift keys to select multiples.
2. 

If OTHER please specify event:  (i.e. Mom's Night Out, Year End Picnic, etc.)
 

3. *

Today's Date:

4. *

Submitted By:

5. *

Phone number:

6. *

May we text you at this number?

Yes No
7. *

Email Address:

8. *

Address:

9. *

City:

10. *

Zip:

11. 

Method of Reimbursement: (NOTE: PayPal is faster and doesn't cost us postage or printing.)

 
Please send me a check. Please send me the money through PayPal.
12. 

My PayPal Email address is:

13. 

Income from Activity: (if applicable) 
List Detail and Amount Collected

14. 

Total Income: $

15. *

Expenditures: (email- preferred or mail receipts)
List each Receipt and Amount:

16. *

Total Expenses: $

17. 

Refund Request: (request submitted by coordinator)
List canceled class or event.

18. 

Total Refund $:

19. *

Please make check Payable to:  (if requesting through PayPal, Re-type your PayPal email)

20. *

Amount: $

Please attach image(s) of your receipt(s) belowor email to resource@lansinghomeschoolers.com
or mail receipt(s) with a copy of your Submitted Reimbursement Form email
to
Michelle McWethy, 2646 Fontaine Trl, Holt MI 48842.

PLEASE NOTE:  Reimbursement checks will not be issued until the receipt(s) are received.

21. 

Comments or Questions:

22. 

Attach Receipts here:


Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip
23. 

Attach Receipts here:


Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip
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