Pioneer PTA Reimbursement Form
2011-2012
You can fill
this form out and then
print it!
Name:
Date:
Phone #:
Please
Sign:
______________________________________
Amount of Bill:
Account Name:
(Acct. Name example: Art Discovery, Grant, Teacher Funds,
Library, etc.)
Please Attach All
Receipts To This Form.
No Receipts, No Reimbursement.
THANK YOU FOR YOUR CONTINUED DEDICATION!
For Treasurer’s Use Only
Payee:
____________________________________________ Date: ________________
Check: #______________ Check Amount:
$______________ Account: _________________
Treasurer Signature:
_________________________________________________________