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CMS PTSA Reimbursement Form
Please complete this form and scan your receipts. Send receipts to Mark Pelusi at Mpelusi@mahanrykiel.com
* Indicates required question
Email
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Record my email address with my response
Full Name of person requesting reimbursement
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Your answer
Home Address of person requesting reimbursement
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Your answer
Phone Number(s) of person requesting reimbursement
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Your answer
Date of Activity
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MM
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DD
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YYYY
Today's Date
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MM
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DD
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YYYY
Program(s) being supported by purchase. Description of what was purchased.
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Your answer
How was this paid for?
Paid for by me, I'm requesting a check for reimbursement.
Paid for on First Financial Debit Card
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Total amount being requested for reimbursement.
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Your answer
Option 1
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Total from Receipt 1 (Circle items and email receipt.)
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Your answer
Total from Receipt 2 (Circle items and email receipt.)
Your answer
Total from Receipt 3 (Circle items and email receipt.)
Your answer
Total from Receipt 4 (Circle items and email receipt.)
Your answer
Total from Receipt 5 (Circle items and email receipt.)
Your answer
Person who approved the activity
*
Margie Ryan
Niesha Johnson
Mark Pelusi
Jennifer Hanss
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