PTO Reimbursement/Disbursement Requests

Instructions:

Fill out this form completely to request:
- a Check Reimbursement for out-of-pocket expenses incurred on behalf of the PTO
- a Check Disbursement payable to a person/company for services
Attach up to 6 files/pictures/scans of all receipts and supporting documentation.
A receipt of your submitted request will be e-mailed to you (please keep for your records).
The treasurer will contact you if additional information is needed.
Questions? Please e-mail our treasurer at mjptotreas@gmail.com.

Name of person submitting request:

Email of person submitting request:

Telephone Number of person submitting request:

What are you requesting?

Check Reimbursement for my out-of-pocket expenses Check Disbursement to a person/company for payment

Total amount requested for Reimbursement/Disbursement:

Make check payable to:

Mail check to the following address:

Activity/Reason for Reimbursement/Disbursement:

Notes to Treasurer:

Attach Receipt/Invoice #1

Attach Receipt/Invoice #2

Attach Receipt/Invoice #3

Attach Receipt/Invoice #4

Attach Receipt/Invoice #5

Attach Receipt/Invoice #6