Neighborhood District Reimbursement Request Form - City of Bend

Neighborhood Reimbursement Request Form

Neighborhood District(Required)

Date(Required)

Who is submitting this request?

Neighborhood Representative Name(Required)

FIrst Name Last Name

Neighborhood Representative Position/Title(Required)

Neighborhood Representative Email(Required)

Who should we reimburse?

Name of Payee(Required)

First Name Last Name

Payee Phone

Payee Address(Required)

Street Number and Name City State / Province / Region Postal/ZIP Code

Total to be reimbursed:(Required)

Expenses

Expense #1

Amount

Store Name, Date, Description of Purchase

Expense #2

Amount

Store Name, Date, Description of Purchase

Expense #3

Amount

Store Name, Date, Description of Purchase

Expense #4

Amount

Store Name, Date, Description of Purchase

Expense #5

Amount

Store Name, Date, Description of Purchase

Are these expenses approved by the neighborhood district board?(Required)

Yes

No

Unsure

Please attach documentation of expenses. The Finance Department requires physical proof that the payment was made. In most cases, receipts provide the appropriate documentation. Invoices may need additional proof of payment, if a payment method and date are not included. Check images are not accepted unless accompanied by a bank statement showing the check was cashed.

Attachment(Required)

Drop files here or

Max. file size: 128 MB.

Additional Comments

Contact

Communications Department
541-323-5977 communications@bendoregon.gov