LSHS Music Parents Association

Request for Payment or Reimbursement

Date: ____/_____/_____
Event/Function: ___________________________________________
Amount Requested: _______________________________________
Requested By: ____________________________________________
Payment Payable To: ______________________________________

Mailing Address: __________________________________________________________

__________________________________________________________
__________________________________________________________

Date Payment Needed: ______________

Summary of Use of Funds: ____________________________________________________

__________________________________________________________________________
__________________________________________________________________________
If request is for reimbursement, is receipt attached?

Yes (receipt is required

for reimbursement)

If request is for payment, please be sure to provide copy of invoice/statement to

treasurer.

(This section for Treasurer Use Only)

Date Deposited:
Account Deposited To:

Date Funds Received by Treasurer: