PTSA Reimbursement & Payment Form

Reimbursement or Payment Form
Submitter's Name*

First NameLast Name
E-mail*
Your E-mail Address
Phone Number
Program to be Charged*

PTSA GeneralLive Events/AuctionSenior SPREEPTSA Grant AwardsTeacher/Staff AppreciationOther
Grant Description
Enter in the SHORT description of your grant.
Grant Season
Enter in the SHORT description of your grant.

Expense List*

	Purchase Date	Description	Cost ($)
1
2
3
4
5
6
7
8
9
10

Total Cost
Receipt*

Cancelof
How would you like to receive your funds?*

Electronic/ACH TransferDirect Payment - Check (Mailed)Direct Payment - Debit Card
Link to pay:
Make Payment To:
Company/Person Direct Check Payment will be written out to
Address to Mail Check

Street Address

Street Address Line 2

CityState

Zip Code
Notes
I certify that all information entered above is valid and true.
Should be Empty:

	
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