Expense Reimbursement Form

Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Expense Description*
Account(s) Chargeable*
- Concessions
- Dive Team
- Swim Team
- Social
- Other
If more than one account, specify amounts to be charged for each in Expense Description.
Total Amount Claimed*
(Enter amount without a $ sign.)
Receipt 1
Max. file size: 2 MB.
Upload scanned copy or photo of receipt. Only one document can be uploaded to each field so create a multiple page pdf if more than two receipts, or email receipts to Admin@LittleFallsSwimmingClub.com.
Receipt 2
Max. file size: 2 MB.
Claimant Signature*

I verify all information provided is accurate.