EXPENSE REIMBURSEMENT REQUEST 

 

               

 

Amici D'Italia Lodge 2791

P.O. BOX 8985

Jacksonville FL 32239-8985

(904)  928-9167

www.osiajax.org  

Category:  Property: ___  Travel:__   Printings Duplication:__  Other:__  (identify)_______________

Name: _______________________________                     Telephone:  _________________________

 

Street Address:________________________  City________________ State____ Zip: _____________

 

Email ____________________________________________     DATE____________________________

 

 

AMOUNT                   DESCRIPTION                         REASON________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________________  

Total: $ ______________    (Attach Receipts)

Please keep same expense items types  together on separate request .   

Please indicate your wishes:  Please consider this a:    ___Donation    ___ Reimbursement request.

 

 

 

Signature__________________________   Authorization____________________________________

                  Your signature                                                              By Lodge 2791

            

The OSIA Amici d’Italia Lodge2791 is a 501c(3) non-profit organization and contributions are

tax deductible.  We are registered with the Division of Consumer Services, Mayo Building,

Tallahassee FL 32399.  Florida residents can call 1 800 434 7352 for information.