Expense REIMBURSEMENT Form

You will need to submit a separate form for each expense for which you are requesting reimbursement.

You must also email (or hand-deliver) receipts to Matt Bloomer (matt@bloomfo.com) with details written on such receipts to explain the expense.

Date

YYYY

Your Name

First Name

Last Name

Your Email Address

This Request is for:

PAYEE INFORMATION

Please provide your information below.

Payee Name

Payee Address

Payee Phone Number

EXPENSE INFORMATION

Amount of Expense

Please provide a brief description and purpose for expense. If total is made up of multiple items, please give a breakdown of each item.

APPROVAL INFORMATION

Requestor E-Signature

Simply re-type your name here.

First Name

Last Name

Authorizing Board Member

The email generated from this form will be forwarded to this Board Member to confirm they have previously authorized this request.

First Name

Last Name

List the Budget Line-Item from which the funds are requested

This will be N/A until we finalize our FY16 Budget

BOARD APPROVAL (if applicable)

If this expense request is greater than or equal to $300.00 (or if it less, but can not be tied directly to a budgeted-for expense in the FY16 budget), then the Board of Directors must approve the request.

Date of Approval by Board of Directors

YYYY

Authorizing Officer

The email generated from this form will be forwarded to this Officer to confirm that the Board has duly authorized the request.

First Name

Last Name

ADDITIONAL INFORMATION

Please provide any additional information here.

Expense REIMBURSEMENT Form

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