Reimbursement Request Form

Where possible please, use HPJC's tax-exempt status to make purchases for HPJC or your organization. Forms and documents to provide to merchants and vendors can be downloaded HERE. If you have already made the expenditures, please remember these documents for the next time you make expenditures for HPJC or your group/organization. These documents can also be downloaded at www.hpjc.org/board-resources.

If you do not wish to use this online form, you may use a hard copy form which can be downloaded HERE Mail the completed form and supporting receipts/invoices to HPJC, Post Office Box 66234, Houston, TX. You may also give the forms, etc. to the HPJC treasurer.

Make Check payable to:*

Enter the complete name you will use to endorse the check

Your email address:*

example@example.com, if you do not have an email address enter _______@noemail.com. Put your name in the blank.

Address which to send the Reimbursement Check*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number:*

Area CodePhone Number

VERY IMPORTANT INFORMATION!

Please do not enter HPJC expenditures in the same submission as expenditures made for non-HPJC budget items, i.e., expenditures made on behalf of a group or organization for which HPJC is holding funds.

Examples of expenditures made on behalf of Houston Peace and Justice Center might include printing costs or supplies for events, programs, or projects that have originated from Houston Peace and Justice Center. If you choose to request reimbursement from Houston Peace and Justice Center funds, you will need to know which HPJC budget item covers the activity or project associated with your expenditure.

You can use this online form for both kinds of reimburesments but you will need to make two separate submissions if you need reimbursements for both HPJC expenditures and for expenditures from funds that are being held for another group by HPJC (non-HPJC group). For example, if you need reimbursement for printing done to publicize the HPJC annual awards dinner and you also need reimbursement for expenditures made on behalf of Food Not Bombs then you must submit two requests.

The next question must be answered in order for your request to be submitted. You may only choose one.

Are you requesting reimbursement for expenditures you made on behalf of:*

Houston Peace and Justice Center, ora non-HPJC group for which HPJC is holding funds?

REIMBURSEMENTS FOR HPJC ACTIVITIES: Describe receipts which cover the expenses for which you are requesting reimbursements. Receipts may cover more than one project/activity/event or more than one HPJC Budget Category. If you do not know the HPJC budget category, contact the HPJC treasurer (info@hpjc.org). Clearly mark receipts so that the items for each project can be distinguished. Also indicate items that are not reimbursable, and recalculate sales tax if applicable. *

	Receipt Date	Vendor/Store Name	Project/Activity	Dollar Total for this Project/Event	HPJC Budget Category
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Form calculated total of requested reimbursement

Please check this total against

REIMBURSEMENT FOR NON-HPJC GROUPS/ORGANIZATIONS. Describe receipts which cover the expenses for which you are requesting reimbursements. Receipts may cover more than one project/activity/event. Clearly mark receipts so that the items for each project can be distinguished. Also indicate items that are not reimbursable, and recalculate sales tax if applicable. *

	Receipt Date	Vendor/Store Name	Project/Activity	Dollar Total for this Project/Event
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10

Form calculated total of requested reimbursement

Please check this total against

Upload Receipts/Paid Invoices that cover the reimbursement(s) you are requesting. You may upload multiple files. File size of each file upload cannot exceed 10 MB. Illegible documents will not be accepted or may have to be forwarded by snail mail. Acceptable file formats are pdf, jpg, jpeg, png and gif. *

Upload

Notes and Comments:

Date of Request:*

MonthDayYear

Provide the name of the non-HPJC group/organization for which the above described expenditures were made.

organization or group name

If you are not authorized to approve reimbursements for your group or organization, that is, if you are not your organization appointed representative to the HPJC board, please provide the name and email address of your organization's appointed representative. After you click on SUBMIT, this form will automatically forward to the email address that you have indicated below along with a request to review and, when appropriate, to send reimbursement approval to the HPJC treasurer.

The person who is serving as the HPJC Board representative from your organization is usually the person who approves payouts (reimbursements) from funds held for your group/organization.

Email Address of Person authorized to approve reimbursements (your organization's appointed representative on the HPJC board.) for your group or organization*

example@Example.org

Please provide your signature below to certify that the above listed items were purchased for use in HPJC activities, events, or projects. Click or tap in the box and use your mouse, track pad, or fingertip to write your signature.*

Please provide your signature below to certify that the above listed items were purchased for use in your group/organization's activities, events, or projects. Click or tap in the box and use your mouse, track pad, or fingertip to write your signature.*

HPJC Expense Reimbursement Form