HomeMy WebLinkAboutReimbursement Request form
CITY OF PALM DESERT
OUTSIDE AGENCY FUNDING AGREEMENT
Request for Reimbursement - Fiscal Year 2018-2019
Agency Name Today's Date
Contact
E-mail address Grant Amount $
Line Date of Cancelled
No. Expense Vendor Name Description Amount Check No.
. , ..
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL $ -
I certify that the expenses listed above are true and correct, and that all necessary receipts, invoices and cancelled checks have been appropriately reviewed to meet the requirements
of the
agreement and attached hereto. I understand that it is my agency's responsibility to submit a reimbursement request upon completion of the agreed-upon services, and that submission after
July 31 of the program year will result in forfeiture of any grant funds awarded.
Signature Name and Title Date