Cub Scout Pack 170

EXPENSE REIMBURSEMENT FORM REQUEST FOR PAYMENT

(complete form, attach receipts, and submit to Pack Treasurer)

Date Submitted:
Person Requesting Reimbursement:
Expense Purpose / Event(s):
Make Check Payable To:
Street Address:
City / State / Zip Code:
Phone Number / Email:

*** Attach all invoices or receipts to this form ***

DATE

EXPENSE DESCRIPTION

DOLLAR AMOUNT
$
$
$
$
TOTAL EXPENSE AMOUNT

REQUESTED REIMBURSEMENT AMOUNT (amount of the check)

If the Requested Reimbursement Amount is less than the Total Expense

Amount, please enter the difference to the right and explain below what the
difference should be applied to:

By signing below, I certify that all expenses list above were incurred for the benefit of the Cub Scouts and I am
requesting to be reimbursed for these expenses.

_________________________________________

____________________

Signature of person requesting reimbursement

Date

_________________________________________

____________________

Approved by Cubmaster or Committee Member

Treasurers Use Only

(Mark one)

Date
Mailed _________

Date of receipt______________________

Check Number: ______________

Date of disbursement_________________

Check Amount: $______________

Hand Delivered __________

Treasurers Initials ___________

Additional Accounting Info.________________________________________________________

Rev 1.00 Updated: September 01, 2014