Splash Teacher Reimbursement Form (Fall 2022)
NOTE: if your intended spending exceeds $30 per class, please first submit a funding request via https://stanfordesp.org/teach/supplementalreimburse.html, ideally before the weekend of Splash.

Fill in the following info and submit the relevant documentation (scan/take a photo and email to stanfordesp.reimburse@gmail.com) in order to initiate your reimbursement process. Documents include
   - A complete, itemized receipt showing not just the total, but EACH item and the cost. This is the only way to prove itemization to SSE, so please make sure some receipt/invoice shows this (notable problem is printing orders).
   - Proof of payment, which is often "Cash/Check $XX.XX" or "Paid by XXXXXXXXXXXX1234" at the bottom of the receipt
       - In some cases, notably Amazon, we need a credit or debit card statement to demonstrate proof of payment, i.e., your name, card number, and relevant transactions.

This reimbursement form must be submitted by the deadline on May 14th 2022.
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Contact Info
Email *
If there is an issue with your reimbursement, we will contact you by this email address.
First Name and Last Name * *
Please put the name you would like the check made out to.
Street Address *
Please put the address you would like the check mailed to.
City *
State *
Zip Code *
Class Number(s) *
Please put the catalog number of the class you taught for which you want class supplies reimbursed. If you would like to be reimbursed for supplies bought for multiple classes, please put all class numbers here separated by commas (e.g. "M1111, S2222, B3333").
Class Name(s) *
Similar to the above, put the full class name as matches the name in the course catalog. You may list multiple class names if you are being reimbursed for supplies used in more than one class, separated by commas (e.g. "Graph Theory, Ancient Civilizations, Developing Vaccines").
Number of Section(s) *
Please put the number of sections you taught for your class. If you are being reimbursed across multiple separate classes, put the total number of sections you taught for each class, separated by commas (e.g. "2, 1, 4").
Students per Section *
You can log in to check your class enrollment numbers. If you taught multiple sections and your sections had different numbers of students attending, you may average across all sections. Please separate for separate classes using commas (e.g. "average of 12, 30, 15").
Reimbursement Info
For each reimbursement, provide the vendor (name of the store or company), description of the supplies purchased from this vendor, and the amount these supplies cost.

Each separate purchase from a different vendor must go in its own field (for example, Vendor 1: Safeway and Vendor 2: CVS).
Vendor 1 *
Please use the most complete name possible for this field (e.g. "Safeway" and not "grocery store").
Supplies Purchased *
Please state exactly what was bought and used for your class (e.g. "ten pencils and one bag of candy").
Amount to Reimburse *
Put exactly how much the supplies you purchased cost. Items that are not Splash class supplies, but included on the same receipt, must be deducted from the total amount.
Have more than one receipt to submit?
Use the additional vendor fields below, one for each receipt. If you only had one receipt to submit, scroll down to the bottom to continue to the next page.
Vendor 2
Supplies Purchased
Amount to Reimburse
Vendor 3
Supplies Purchased
Amount to Reimburse
Vendor 4
Supplies Purchased
Amount to Reimburse
Vendor 5
Supplies Purchased
Amount to Reimburse
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