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Lomira Parents and Teachers For Children

Reimbursement Request Form Date Submitted:

_____________________________________

Requested By:

_____________________________________

Funds Allocated To Teachers Program (FATT) PTC General Fund

DATE

ITEM DESCRIPTION/PURPOSE

AMT

TOTAL AMOUNT: Legible copy of itemized receipt(s) or invoice(s) attached Route check to requestor via inter-school mail Use alternate instructions provided below Check Payable To: _____________________________________ Mail to Address:

_____________________________________ _____________________________________

_____________________________________________ Approved by PTC Executive Board Member

Check # Date Account Amount


Lomira PTC Reimbursement Request Form