CHESS Reimbursement/Refund Form

List the activity or event for this Reimbursement/Refund:

Today's Date:

Submitted By:

If you are submitting this for someone else, please indicate who the reimbursement is for (if this is for you, enter "NA"):

Phone number:

May we text you at this number?

Email Address:

Confirm PayPal email address:

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

Total Income: $

Expenses - list each receipt and amount:

Total Expenses: $

Refund request for cancelled class or event:

Total Reimbursement (income - expenses + refund): $

Comments or Questions:

Attach Receipts here:

Attach Receipts here:

Attach Receipts here:

Attach Receipts here:

Attach Receipts here: