Qualified Reimbursement & Check Request Form

Today's Date

Department

Department Head

Department Secretary

Who is making this request

Requester's Email

This address will receive a confirmation email

Requester's Phone

Reimbursement or Check Request

Amount of Check

Write Check to

Mail Check to

Event or Purpose

Note 1: If you take people out for a meal you MUST list everyone's names and the purpose of the meal.

Note 2: If any part of this request is for an honorarium you must provide a signed and dated IRS form W9.

Please list where you purchased items, what you purchased, and the amount of purchase.

Item(s) Purchased

Additional Notes if needed