Region Payment Request Form

Mail Check To (For Check Payments)
A valid receipt must include detail of items purchased. If this request is related to mileage, please upload map data to support total trip mileage. If you have any troubles uploading the file, please email it to priscilla@civitan.org
Drop files here or
Accepted file types: jpg, gif, pdf, png, word, excel, Max. file size: 32 MB.
    Max. file size: 32 MB.

    *Once your request has been submitted, please allow 14 days for processing. If you have any questions about the status of your reimbursement, please contact Priscilla Denard at priscilla@civitan.org.