Reimbursement Form

Fill out reimbursement form completely to prevent delays in processing your request.

1. Provide a detailed description of the reason for this request.

2. The expenditures will be charged to the Ministry requesting reimbursement.

3. Allow at least 2 weeks for processing of reimbursement.

4. ALL monetary transactions shall be documented by way of this form and pre-approved prior to making any purchases by CORE Leaders or Operations Management.

Your name *

Email address *

Date Request is being submitted: *

Date Reimbursement is needed by: *

PAYMENTS

ALL payments will be mailed to address stated below.

Payable To: *

Please put your full name as it appears on your drivers license / state ID.

Amount that is being requested. *

Address

REIMBURSEMENT APPROVAL

Was this purchase preapproved? *

Yes

RECEIPTS/ INVOICE

Detailed description of purchases. *

Proof of purchase. *

Please upload ALL receipts for record keeping.

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SIGNATURE

Electronic Signature *

Click here to submit your signature electronically.