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Orchard HSA Deposit Request
Note:
For Event/Activity generating greater than $500 in proceeds:
a) Please provide a support schedule. Schedule can be in excel or handwritten
b) Proceeds must be counted by two people, typically the event Chairs. If there is only one event Chair, then the second person must be the HSA President or Treasurer
c) Both people must sign the Deposit Request form

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Email *
Date *
MM
/
DD
/
YYYY
Category/Event to be Charged *
Amount (Please email Elizabeth Segarra an itemized breakdown at liz.christenson326@gmail.com): *
Electronic Signature: *
**Electronic Signature 2:
A copy of your responses will be emailed to the address you provided.
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