Form

PALY Request for Payment / Reimbursement
Instructions:

1) Complete form. 2) Upload copy of receipt(s) or print form & attach receipt(s). 3) Hit "Submit." (If mailing, also hit "Print;" then mail form with receipt(s) to address at page bottom. Allow 6-8-weeks for check to arrive. Problems / Questions? Contact: Gary Paladin (garypaladin@sbcglobal.net) or Joel Spolin (joel_spolin@yahoo.com).
Date*
Month Day Year
Requestor Name:*
First Name Last Name
Requestor Email*
Requestor Phone:*
- Area Code Phone Number
Payee (if different from Requestor)
First Name Last Name

Mailing Address for Check:*

$ Amount Requested*
Attach Receipt(s)
Descripton of Purchase (Be Specific)*
Expense Category Code (Choose One)*
Special Instruction (if any)
This Section to be Completed Only By Teachers
Teacher Advisor Funds (Check if Appropriate)

Max Reimbursement = $150 / Yr
Stay Connected Funds (Check Appropriate Level)

Teaching 81% to 100% Time (Max Reimbursement = $150 / Yr Teaching 51% to 80% Time (Max Reimbursement = $100 / Yr) Teaching < 50% Time (Max Reimbursement = $75 / Yr)
Hit "Submit" below. If mailing, also hit "Print." Then attach receipts & send to:

PTSA Treasurer, c/o Gary Paladin, 1533 Dana Avenue, Palo Alto, CA 94303. Allow 6-8-weeks for check to arrive. Keep a copy for your records.
Should be Empty:

PALY Request for Payment / Reimbursement