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EHPTSA Expense Reimbursement Form

* indicates a required answer.

This form is to be submitted for reimbursement for previously agreed upon budget items. 

Please complete and submit the following form, after submission turn in your receipts to the EHPTSA treasurer.

1. *

Reimbursement Request Date: (MM/DD/YYYY)

2. *

Member Name:

3. 

Mailing Address if reimbursement check is to be mailed:

4. *

Phone Number:


 

Itemized Expenses 

Receipt 1:

5. *

Date: (MM/DD/YYYY)

6. *

Description/Items:

7. *

Vendor/Store:

8. *

Amount:


 

Receipt 2:

9.

Date: MM/DD/YYYY

10. 

Description/Items:

11.

Vendor/Store:

12.

Amount:


 

Receipt 3:

13.

Date: MM/DD/YYYY

14. 

Description/Items:

15.

Vendor/Store:

16.

Amount:


 

Receipt 4:

17.

Date: MM/DD/YYYY

18. 

Description/Items:

19.

Vendor/Store:

20.

Amount:


 

Receipt 5:

21.

Date: MM/DD/YYYY

22. 

Description/Items:

23.

Vendor/Store:

24.

Amount:


 

Receipt 6:

25.

Date: MM/DD/YYYY

26. 

Description/Items:

27.

Vendor/Store:

28.

Amount:


 

Receipt 7:

29.

Date: MM/DD/YYYY

30. 

Description/Items:

31.

Vendor/Store:

32.

Amount:


 

Receipt 8:

33.

Date: MM/DD/YYYY

34. 

Description/Items:

35.

Vendor/Store:

36.

Amount:


 

37. *

Subtotal:

38. *

Less Cash Advance:

39. *

Total Reimbursement:


 

40.*

By Checking This Box I am Signing my Signature To This Expense Reimbursement Fund To Be Reimbursed For Previously Approved Budget Items:

 (1 required)
My Signature for Reimbursement: