Reimbursement Requests/Invoice Submissions Form

Reimbursement Requests/Invoice Submissions

Form for Funds requesting reimbursements/invoice submissions.

"*" indicates required fields

Fund Name*

Your Name*

Your Phone #

Your Email*

Enter Email Confirm Email

Payee Name*

Have you previously submitted contact information related to this payee?*

Yes

Payee Address

Street Address City State / Province / Region ZIP / Postal Code

Itemized Expenses*

Please list expenses by date, description of expense, purpose of expense, and amount. Receipts/invoices are required for all payments. (Use the + icon to add more rows – one row for each expense).

Receipt Date

Description

Explain purpose and use of this purchase

Amount

Total Amount:*

This is the total of all itemized expenses.

Is this expense related to a fundraiser?*

Yes

Receipt of Payment

Recipient will pick up check (Requests received by end of business Tuesday can be picked up on Fridays after 2 p.m.)

Forward check to Payee listed above.

ACH Payment (Direct Deposit)

Special Instructions (Please explain below)

Have you previously submitted bank information for this payee?*

Yes

ABA/Routing Number*

Bank Account Number*

Receipts/Invoice Upload*

Please upload a scan, photo, or otherwise digitally formatted receipt or invoice for each payment. Receipts or invoices are required for all payments. PDF Documents Only

Drop files here or

Max. file size: 1 GB.

Special Requests

Please explain here if you have a special request for your payment. or if there’s anything else we need to know to process your request.

Fund Rep Approval*

By typing your name in this box, you certify that you are authorized to make payment requests on behalf of the Fund stated above.

This field is for validation purposes and should be left unchanged.

216 Franklin St. Suite 400, Johnstown, PA 15901
(814) 536-7741

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