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CHESS Reimbursement/ Refund Form

indicates a required answer

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. *

Email Address:
6. *

Address:
7. *

City:
8. *

Zip:
9. 

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.
10. 

My PayPal Email address is:
11. 

Income from Activity: (if applicable) 
List Detail and Amount Collected
12. 

Total Income: $
13. *

Expenditures: (email- preferred or mail receipts)
List each Receipt and Amount:
14. *

Total Expenses: $
15. 

Refund Request: (request submitted by coordinator)
List canceled class or event.
16. 

Total Refund $:
17. *

Please make check Payable to:  (if requesting through PayPal, Re-type your PayPal email)
18. *

Amount: $

Please email copies of your receipt(s) to [email protected]
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.
19. 

Comments or Questions:
20. 

Attach Receipts here:
Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip
21. 

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