Blank reimbursement form.xlsx

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2	Treasury Policies Manual
3	Payment and Reimbursement Request Form
4	Revised 07/2016
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6	Mill Hill School PTA (MHS PTA) Payment and Reimbursement Request Form
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8	Instructions and Reminders:
9	- Expenditure must be approved by Committee Chair, WITHIN BUDGET LIMIT, and authorized with signature below.
10	- Remember to use the MHS PTA SALES TAX EXEMPTION; sales tax will NOT be reimbursed.
11	- Expenditures for $600 or more will not be reimbursed without receipt of a copy of the vendor's FORM W-9.
12	- Attach original, itemized receipts and/or invoices to the completed reimbursement request.
13	- All requests for reimbursement should be submitted to the MHS PTA Treasurer WITHIN 30 DAYS OF THE EVENT OR PURCHASE.
14	- Notify the MHS PTA Treasurer when the completed Request Form and documentation has been submitted in the PTA Treasurer’s file folder in the PTA filing cabinet.
15	- For clarification, review the Treasury Policies Manual Treasury Guidance for Committee Chairs for detailed instructions on payments and reimbursements.
16	- Contact the MHS PTA Treasurer with any questions: millhillptatreasurer@gmail.com.
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18	Date Request Submitted to Treasurer:		6/11/26
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20	Claim Submitted By:	Christen Davis			Contact Email:	cdutchka@hotmail.com
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22	MHS PTA Committee:		Staff Appreciation
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24	Description of Expense / Event:		Bagels for Staff-End of school year thank you
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26	Budget Line Item Expense Applies to (see Treasury Policies Manual Account Line Items, Descriptions and Responsibility):							52705
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28	Approved By (Circle One): PRESIDENT PRESIDENT ELECT VICE PRESIDENT				Signature:
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30	Reimbursement Check or Payment Payable to:			Christen Davis
31	Mail Reimbursement Check or Payment to:			63 Rita Ave.
32				Fairfield, CT 06824
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35	Date of Purchase	Vendor		Description of Items Purchase				Amount
36	06/10/26	PopUp Bagels		3 Big Boxes of Bagels w/cream cheese & butter ($95/box)				$ 285.00
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51	Total Reimbursement or Payment Requested							$ 285.00
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53	...…………………………………………………………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………...……………………………………………………………………………………………………………
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55	This Section For MHS PTA Treasurer Use Only:
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57	Date Received		Check Date		Check Number		Amount Paid
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59			Account #	Account Name
60	PTA Budget Line Item:
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62	Funds Available (Circle One):		YES	NO
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64	W-9 Required (Circle One):		YES	NO	On File (Circle One):	N/A	YES	NO
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66	Authorized Signature (Treasurer):
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68	...…………………………………………………………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………...……………………………………………………………………………………………………………
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