District Reimbursement Form | Civitan International

Region Payment Request Form

Name of Person Filling Out Form (Must Be Policy & Procedure Chair)

Policy & Procedure Chair Email

Region

Have you received prior authorization from your Region Director? Please provide proof of approval.

Reimbursement or Invoice

Invoice Due Date (if applicable)

Name of Payee

Form of Payment

Total Amount To Be Paid

Expense Description

If chose "other" above, please describe in more detail here:

Payee's Email

Mail Check To (For Check Payments)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Upload receipts/invoice here (photos or scans)

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.

If payee is an independent contractor, upload their W-9 here:

Max. file size: 512 MB.

Comments Concerning Payment Request

*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.

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