PTO Reimbursement Form

Instructions:

1. Fill out completely with description of reimbursement and corresponding committee (missing info will delay payment).

2. Attach one file with copies of all receipts.
3. A receipt of your submitted request will be emailed to you (keep for your records).

Reimbursement Information

Check Payable To:

Total Amount For Reimbursement:

Mailing Address

Expense 1 - Amount

Committee to Be Charged

Expense Is For:

Place of Purchase

Receipt for Expenses 1