Reimbursement Form , 2009 EC Patriots

Please answer all of the questions to receive a reimbursement for your expenses. Once your request is received, please allow a few weeks to process your check.

After you have completed this form, PRINT (Ctrl+P) a copy for your records, and send another COPY along with COPIES of your receipts to: EC Patriots, Attn: Reimbursement, PO Box 1502, Ellicott City, MD 21041.

Please send only COPIES of your receipts--keep your receipt originals for your own records. Thank you.

* Required

[1] Your Name: * (the check will be made out to this name)

[2] Your Postal Address: * (Street, City, State and Zip)

[3] Your Phone Number: * (in case of questions)

[4] Total Reimbursement Amount: * (total of all receipts)

[5] Purchase Details from Receipts: * (list the vendor, item, date and amount of purchases. please save your receipts...)

[6] Was This Expense Budgeted? * (if unsure, indicate "no")

[7] Name of Board Member Approving This Expense: (required if you indicated "no" to [5], or [3] is in excess of $250)

[8] Purpose of the Expense: * (please choose best answer from the list)

[9] Other Expense Explanation: (use only if you specified "Other" above)