Rose Tree Media School District
INDIAN LANE ELEMENTARY SCHOOL
Parent Teacher Group (PTG)
REIMBURSEMENT FORM 2013-2014 SCHOOL YEAR
PLEASE READ: Please complete all information on this form, attach receipts (staple, please),
and return it to Mary Kate Hewlings. Approved expenses with all required paperwork will be
reimbursed.
DATE OF REQUEST: ____ /____/____ DATE OF EVENT / EXPENSE: ____ / ____ / ____
PAYABLE TO:
______________________________________________________
______________________________________________________
(or Child’s Teacher for delivery via classroom)
______________________________________________________
MAILING ADDRESS:
COMMITTEE/
EVENT:
________________________________________________________________
INCLUDED IN BUDGET _______ Y/N BUDGET ALLOWANCE: $_______________
(please check with Chairperson of committee or Treasurer if necessary)
NOTES:
________________________________________________________________
________________________________________________________________
TOTAL AMOUNT
TO BE REIMBURSED: $ ___________
ALL RECEIPTS
ARE ATTACHED: _____ YES
SUBMITTED BY:
________________________________________________________________
SIGNATURE:
________________________________________________________________
AUTHORIZED BY:
________________________________________________________________
(Committee Chairperson/PTG President’s Signature or copy of email from that person authorizing expense)
PLEASE KEEP A COPY OF THIS COMPLETED FORM AND ALL RECEIPTS FOR YOUR
RECORDS
Thank you for providing your receipts,
Check # _____________
Mary Kate Hewlings, PTG TREASURER
Amount Paid $ ________
Email: mkfeb@yahoo.com
Date Paid: ____________