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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. *

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