Copy of Reimbursement Form (Includes Fillable Fields)

This blank copy of the reimbursement request* form is only for active grantees with an approved agreement on file.

If you have not submitted an application for funding to us yet, you can learn how to here: What is the Express Program and how do I apply?

*The attached reimbursement request form is editable. Please download and use a pdf reader such as Adobe or Nitro to fill-in the fields. You may not be able to see the fillable fields in a browser version of a pdf reader. For the Authorizing signature line, if you have access to an online signature tool, you are welcome to use that, or you can sign the form manually, then scan and submit to us. We are unable to accept a typed name as a signature.