Payment Request Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Reimbursement Amount Total(Required)

Date Check Needed

Checks are issued weekly. If you have an urgent request, please add that in the notes. Otherwise expect your check within seven days.

Make Check Payable To(Required)

First and Last Name or Company Name

Address (Check Delivered To)

Hill Elementary (all teacher reimbursements will be delivered to school weekly)

Other Address (list below)

Other Address (Check Payable To)(Required)

Street Address Address Line 2 City State ZIP Code

Account To Be Debited(Required)

If you don’t know what account to charge, describe what the purchase is for

Itemized Requests

Item

Place of Purchase

Amount

Total

If your invoice reflects more than one account, please identify each and the amount that should be deducted from each. Remember to use the sales tax exemption certificate when purchasing items for PTA use. SALES TAX WILL NOT BE REIMBURSED

Remarks

Attach receipt(s)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Upon successful submission of this form, you will receive a confirmation message and an email. If you do not receive this, your form was not successfully submitted. Scroll up to see any error messages or omitted fields. Contact treasurer@hillelementary.com if you have any questions.

Comments

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