District Reimbursement Form

Policy & Procedure Chair Name(Required)

First Last

Policy & Procedure Chair Email(Required)

Have you received approval from your International Director for this reimbursement?(Required)

Total Amount of Reimbursement Requested(Required)

Expense Description(Required)

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

SEND PAYMENT TO:(Required)

First Last

Reimbursee Name

Reimbursee's Email(Required)

Address(Required)

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

Upload receipts here (photos or scans)(Required)

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.

Drop files here or

Accepted file types: jpg, gif, pdf, png, Max. file size: 32 MB.

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

Max. file size: 32 MB.

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*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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