Check / Reimbursement Request
The receipt(s), bill, quote, or statement for the total amount MUST be attached for a check to be issued.
Date Submitted: __________________ Project / Committee: _______________________
Your Name: ________________________________ Phone: _____________________
Email: _______________________________________________
Check Payable to:
___________________________________________________________________
Amount: $________________________
Description of expenditure: _____________________________________________________
Have you attached the receipt(s), bill, quote, or statement?
How should the check be delivered?
Yes No
Mail to (include entire mailing address):
________________________________________________________________________
Back Pack Mail ____________________________________________________________
Child’s Name Teacher Grade
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For Treasurer’s Use Only
Included in annual budget
1 st PTO Officer Approval: ________________
2 nd PTO Officer Approval (if over $1000):___________________
Check # ________ Date: _________ Mailed: _________