Reimbursement Request
Complete this from to receive a reimbursement for eligible purchases on the next payment run. Please note: 10% processing fee will be applied on top of the reimbursement total and charged to the package.
Members full name
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Members Date of Birth
*
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Day
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Month
Year
Your email address
example@example.com
Select below who should receive this reimbursement
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Member
Authorised Representative
Date of purchase (Purchases outside of the 30 day reimbursement terms may not be accepted)
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Month
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Day
Year
What has been purchased?
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Total value being requested for reimbursement
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Please upload receipt or proof of payment and any relevant documents
*
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Purchases must be an eligible item and be listed in your Help Plan and Budget.
*
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