Payment Reimbursement Form
Instructions and Notes:
Receipts
Need to include the store name, date, items, and total amount
If you are only claiming part of a receipt, please
CIRCLE
the item(s) you want reimbursed and add a note of clarification to the comments section
If you have any personal expenses on a receipt, you cannot claim the whole receipt.
Taxes
Fully reimbursable as long as you are claiming the whole receipt.
The Foundation will NOT reimburse tax on receipts that cannot be claimed in full
Timing
Please allow up to 3 weeks to receive your check
If you do not receive a check in 3 weeks, please email
ptolm-assistanttreasurer@aak8.org
to inquire.
Name (as you want it written on your check)
*
First Name
Last Name
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of receipts
*
Which applies?
*
I am claiming full reimbursement on ALL receipts
I am claiming only some items on at least one receipt
Total amount to be reimbursed
*
Reason(s) for reimbursement
*
examples: Fall Party, spring basket, etc.
Grade (required for room parents and helpers)
*
N/A
KP
K
1
2
3
4
5
Middle School
RPC Expense
PTO
Receipt(s)
*
Browse Files
Must show store name, date, items, and total price to be valid.
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of
Comments (optional)
Submit
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