* Required Information
Please review the following before submitting reimbursement request:

  • Only goods approved in the Community Support Plan will be reimbursed.
  • Reimbursements should be submitted within 10 months of the date of purchase.
  • Proof of payment must include the purchase date, item description, and amount paid.
  • All receipts and/or order confirmations should be attached to this form.

Purchase Date Description Budget Category Amount
Total Reimbursement Rate
$

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