Reimbursement Request Checklist Please check each item and include the following in your FAC Reimbursement Packet: Name of Organization approved for FAC funding: _______________________________________ Reimbursement is payable to: ________ Individual Student (CWID:______________________) ________ Student organization ________ Organization Advisor (CWID: ___________________) Amount of Reimbursement: $__________________ (double-check that receipts total this amount) Partial Reimbursement
In-Full Reimbursement
Contact information for packet:
Mailing address the check will be sent to:
Name: ____________________________
__________________________________
Phone:____________________________
__________________________________
Email:____________________________
__________________________________
__________________________________
__________________________________
Proofs of Purchase (receipts)
Proofs of Payment (bank statement or copy of credit card used)
Direct Deposit Authorization Form
Additional details: ________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________