Request for Reimbursement

Pacific Middle School PTSA

Name of Person to Receive Reimbursement

Address                                                                                                                                        _____

Date  Telephone Number

Total Amount of Reimbursement

Description of Reimbursement (Items or Service – Attach Receipt)

Committee or Project

                                                                                                    Signature of Committee Chairperson

Check #  Check Date

                                                                                                                            Signature of Treasurer