2022-2023++Request+for+Reimbursement_Form.xlsx

	A	B	C	E	G	I	J	L
1
2				REQUEST FOR REIMBURSEMENT
3
4
5
6
7
8	Remember that if item total $500.00 or more, three qualifying bids must be attached from vendors.
9
10
11	QTY	ITEM DESCRIPTION			ITEM #		PRICE EA	PRICE EXT
12
13								-
14								-
15								-
16								-
17								-
18								-
19								-
20								-
21								-
22								-
23						TOTAL		$0.00
24
25	Briefly Describe the purpose/reason for the request (please indicate if this is Prevention Plan, Cannabis, or Social Norms funding)
26
27
28
29
30	Reimbursement to:
31	Address:
32
33
34
35			Originator's Signature
36
37			Date
38
39			INSTRUCTIONS FOR COMPLETING REQUEST FOR REIMBURSEMENT FORM
40
41	1. If a W9 form has not been completed, one will be needed before reimbursement.
42	2. Each purchase should have an invoice with the name of the company, date, etc.
43	3. If purchases are over $500, three written bids must be obtained before purchase is completed. Exceptions
44	are honorariums for speakers negotiated per individual invited to fulfill a specific need and products that are
45	uniquely provided by a single company.
46	4. Documents should be emailed to matthews@ticua.org.
47	5. Reimbursements must be submitted by the second to last Friday of each month in order to be processed in the same month.
48
49	6.13.2022
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100