Spiritual Assembly of the Bahá’ís of Philadelphia, PA

2462 Bryn Mawr Avenue	Philadelphia, PA 19131

215-879-8866

REIMBURSEMENT CHECK REQUEST	Date

OR IN-KIND RECEIPT REQUEST

FORM IS FILLABLE. PLEASE SAVE WITH A DIFFERENT NAME.

Value must be ascertainable. This form is not for in-kind contributions where donor determines value.

Name

Address

Bahá’í I.D. Number (required)

NOTE: We are TAX EXEMPT. Sales tax will be reimbursed or credited for purchases totaling $100 or less. Before purchasing items totaling more than $100.00, please consult the Treasurer.

Amount Requested	Date Needed

Please Check Appropriate Boxes:

In-kind Contribution	Reimbursement Check

Store Receipt attached or	Store Receipt Attached (required)

Independent Appraisal Attached

(one of these two required)

Reason for Contribution or Expenditure:

Please email completed form to Treasury.phila.bahai@gmail.com.

Committee Use Only:

Committee Authorizing Expenditure	Budgeted	Not Budgeted

For Treasurer’s Office Use Only:

Amount	__________________

Check/Receipt #	__________________	Check/Receipt date	__________________

Vendor No.	__________________

Expense /Asset Acct #	__________________	Project

In-kind Income Acct #	__________________	Project

Budget Line(s)	__________________