Reimbursement Request Form

Please fill out all required fields.

Please fill out all Submitter information.
Date of Submission * / MM / DD YYYY
Name First Last
Email *
On Behalf of Someone Else? *
Yes No
Name - If different from submitter First Last
On Behalf of Email
Address (Or On Behalf of Address) *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If you are submitting on behalf of someone, please list the address of the person you are submitting the request for.
Phone * - ### - ### ####
Details of Expenses #1

Please itemize expenses if different expense has multiple ministry codes.
Date of Expense #1 * / MM / DD YYYY
Details of Spending #1 *
Expense Amount #1 * $ . Dollars Cents
Ministry Code #1 *
Upload Receipt for Expense #1 *

Attach Files Attach Files
Details of Expenses #2

Please itemize expenses if different expense has multiple ministry codes.
Date of Expense #2 / MM / DD YYYY
Details of Spending #2
Expense Amount #2 $ . Dollars Cents
Ministry Code #2
Upload Receipt for Expense #2

Attach Files Attach Files
Details of Expenses #3

Please itemize expenses if different expense has multiple ministry codes.
Date of Expense #3 / MM / DD YYYY
Details of Spending #3
Amount of Expense #3 $ . Dollars Cents
Ministry Code #3
Upload a Receipt #3

Attach Files Attach Files
If you have additional expenses, please submit another reimbursement request.

As we mature the reimbursement process, we will continuously look for ways to improve. Thank you for understanding.
Please email payments@odpcec.org if you have any questions regarding the reimbursement process.

By submitting this form, I confirm that items purchased (or will be purchased) will be used solely for the ministry specified above. I have made a reasonable effort to get the best price possible and confirm that there were no conflicts of interest in making this purchasing decision.
Full Name *

I confirm the above statement.
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Reimbursement Request Form

Reimbursement Request Form

Please fill out all Submitter information.

Details of Expenses #1

Details of Expenses #2

Details of Expenses #3

If you have additional expenses, please submit another reimbursement request.

Please email payments@odpcec.org if you have any questions regarding the reimbursement process.

Scroll up after you click "CONTINUE"