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CHESS Reimbursement/ Refund Form

* indicates a required answer.

1. *

List the Activity for this Reimbursement/ Refund:  (i.e. Academic Co-op Period, Enrichment Day, Year End Picnic, etc.)
 
2. *

Today's Date:
3. *

Submitted By:
4. *

Email Address:
5. *

Address:
6. *

City:
7. *

Zip:
8.

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.
9.

My PayPal Email address is:
10. 

Income from Activity: (if applicable) 
List Detail and Amount Collected
11.

Total Income: $
12. *

Expenditures: (email- preferred or mail receipts)
List each Receipt and Amount:
13. *

Total Expenses: $
14. 

Refund Request: (request submitted by coordinator)
List canceled class or event.
15.

Total Refund $:
16. *

Please make check Payable to:  (if requesting through PayPal, Re-type your PayPal email)
17. *

Amount: $

Please email copies of your receipt(s) to resource@lansinghomeschoolers.com
or mail receipt(s) with a copy of your Submitted Reimbursement Form email
to Krista Royston, 2157 Candlewood Dr, Charlotte, MI  48813.

PLEASE NOTE:  Reimbursement checks will not be issued until the receipt(s) are received.
18. 

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