CHESS Reimbursement/Refund Form

indicates a required answer

1. *

List the activity or event for this Reimbursement/Refund:

2. *

Today's Date:

3. *

Submitted By:

4. *

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

 

Please enter the following information for the person who is being reimbursed.

5. *

Phone number:

6. *

May we text you at this number?

Yes No
7. *

Email Address:

8. 

Confirm PayPal email address:

9. 

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

10. 

Total Income: $

11. *

Expenses - list each receipt and amount:

12. *

Total Expenses: $

13. 

Refund request for cancelled class or event:

14. *

Total Reimbursement (income - expenses + refund): $

15. 

Comments or Questions:

 

Please attach image(s) of your receipt(s) below or email to resource@lansinghomeschoolers.com
(ONLY PDF or JPG files will be accepted)

16. 

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
17. 

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
18. 

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
19. 

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
20. 

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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