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BCMS HSA Store
HSA Reimbursement Form
Instructions:
1. Complete form with description of reimbursement and breakdown of expenses.
2
.
Attach one file with copies of all receipts, preferably a PDF.
3.
A receipt of your submitted request will be emailed to you (keep for your records).
Reimbursement Information
Full Name
Mailing Address
Phone Number
Check Payable To:
Amount For Reimbursement:
Breakdown of Expenses:
Account to Be Charged
Office Expense
General Expense
Mini Grants
Fall Party
Gifts
Staff Appreciation
Food
Spirit Day
Socials
Helping Hands
Communications
Other
Event of Project Description:
Place of Purchase
Attach Receipts
Please attach one file with copies of all receipts
Child's Name:
Child's Grade:
5th
6th
7th
8th
Multiple Children
Treasurer's Notes
(To be completed by the Treasurer)
Date Check Issued
Check Number:
Notes
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