Reimbursement claim form

	A	B	C	D
1		REGION 7 -- REIMBURSEMENT CLAIM FORM
2		REGION 7 -- REIMBURSEMENT CLAIM FORM
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4	Name:		Date:
5	Phone:		Home or Work Number?
6	Address:
7	City:		Zip Code:
8	Email:
9	Reimbursement from ACSA Region 7 for these expenses (list and describe below):
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14	This purchase/expense was authorized (check one):
15		Please Select One
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17	Items to be reimbursed (Attach ALL receipts for meals, housing, or materials):
18		Item	Amount	Reciept Attached
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25		TOTAL TO BE REIMBURSED	$ -
26		The expenditures above were incurred in ACSA Region 7 business and are not reimbursed by any other funds.
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29			Signature
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32			Treasurer Approval
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34		Send to: Araseli Zamora, C/O Waterford USD - 219 N. Reinway Ave., #2, Waterford 95386
35		Scan & email to: azamora@waterford.k12.ca.us
36		For questions call:
37		Phone: 209-480-0094 (Cell)
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