CLIPCO Expense Reimbursement/Check Request Form

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Full Name *

Check will be payable to this name.

Address *

Check will be mailed to this address. If you can pick up at Muir, put "Muir office". If you're at Miller, put "Miller".

Email address *

All communication and a .pdf copy of this request will be sent to this email address.

Date of expense *

YYYY

School *

Muir Elementary School

Miller Middle School

Combined School (ASEP, Graduation, CLIPCO Administration Expenses)

Description of Purchase *

Please list general description of expenses and purpose.

For instructional materials (Muir only), please enter a detailed description of the items (e.g. pens, stickers, fidget toys, etc).

Amount ($) *

If you have multiple receipts, please add up your total amount and list here.

Category *

See Category and Subcategory List here: https://goo.gl/W9Btv8. If you have multiple expenses in different categories, you must submit a new form for each category.

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