Reimbursement Request Form

Please submit the following account of expenses incurred for services or materials 

for which you are requesting reimbursement from TLWGA. 

Please ATTACH ANY RECEIPTS to this request for reimbursement.

Description of expense or service:






Total Cost/Request for Reimbursement  $______________________

Requested by:  Name__________________________________________Date_________________

Address where check will be mailed:

_______________________________________________________


________________________________________________________

Please prepare a check payable to:_____________________________________________

Attach receipts or other paperwork.

Mail or give this request and receipts to:

Ruth Williams
5965 New England Woods Dr.
Burke, VA 22015

xxxxxxxxxxxxxxxxxxxxxxxxxxxx

Do not write below this line______________________________________________
(for Treasurer use only)

Check number_______________________________________

Budget Area of Allocation____________________________






                       
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Deborah Smith,
Feb 3, 2019, 10:04 AM