Odyssey PTA Reimbursement Request Form

REIMBURSEMENT REQUEST FORM

Please fill this form out as completely as possible. All purchases made by a volunteer must be authorized by an Odyssey teacher or a PTA Board member in advance. Receipts are required for reimbursement. Please direct questions to Dan Soltesz, Odyssey PTA Treasurer, at dan.soltesz@odysseyprogram.org.
Date of Reimbursement Request *

Month Day Year
Date
Requestor Name *
Check Payable To *
Name of Individual/Company
Address (if check will be mailed)

Street Address

Street Address Line 2

City State

Zip Code
Description of Expense(s)/Reason for Reimbursement *
Reimbursement Amount Requested *
Please enter a number without a dollar sign.
Expense Category *

Classroom Expense Field Study Performance PTA/School Support Fundraiser Investment
Cluster (if more than one cluster is selected, explain breakdown in "notes" field) *

K12 345 678 All School
Name of Odyssey staff or PTA board member who approved this purchase *
Payment Delivery *

Teacher Mailbox Leave with School Secretary Mail
Take a Photo of Your Receipt (Usually for a Smartphone)
Upload a File with Your Receipt (Usually for a PC)
For PTA Treasurer use only
Check #
Payment Date

Month Day Year
Date
MM Entry Date

Month Day Year
Date
Should be Empty:

REIMBURSEMENT REQUEST FORM