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Springfield Public Schools R12
Kraft Administrative Center
Educational Services
1359 E. St. Louis St
Springfield, MO 65802
Phone: 417-523-0014
Fax: 417-895-2007
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All documentation illustrating requestor’s initial
payment of amount requested MUST be attached
to this form at the time of request. For items
charged to a credit card, please include a copy of
the credit card used with all but the last 4 digits of
the card number crossed out.
This form should only be used for non-travelrelated expense reimbursement from Title IIA
Funds.
Requestor must be set up as a Vendor with the SPS
Finance Department PRIOR to submitting a
reimbursement request. Requestor may complete
and mail a W-9 form to the attention of Kellie
Groh, or she can be reached at 417-523-0076.
Requestor’s Name, Address, & Phone#_____________________________________________
Name of School:________________________________________________________________
Quantity
Description
Unit Cost
Total Cost
$ 0.00
$ 0.00
$ 0.00
Total Reimbursement Request:
Signature of Person Submitting Request
Requestor’s Vendor Number
Signature Non-Public School Administrator
SPS Budget Code
Associate Superintendent, Educational Services
$ 0.00