Request for Disbursement Thank you for your support of the Brooks PTA. Please complete the form below. Please enable JavaScript in your browser to complete this form. – Step 1 of 3Please select which best applies best to you:I am a Brooks teacherI am a volunteerMini-Grant Guidelines: Individual Classroom/teacher grant project up to $300.00 Entire grade grant project up to $900.00 Department Project (Reading, Math, Science, etc.) can exceed $1,000 but no more than $1,200 If these amounts are within your needed range, please click Next to proceedNextPlease select *I am seeking a PTA mini-grantI am seeking a field trip reimbursement or advance paymentI am seeking funding from the Teacher General Allocation FundI am seeking reimbursement for a different PTA Pre Approved ExpenseTeacher General Allocation Fund permits up to $200 in disbursement for supplies for instructionName *FirstLastEmail *Grade Taught or Relationship with School *Total Grant Amount *Amount of grant your group is applying forTotal Field Trip Amount *Total Amount of reimbursement or advanced payment for field trip you / your group is requestingTotal Funding Requested *Teacher General Allocation Fund permits up to $200 in disbursement for supplies for instructionDescription of the Project or Item *Name *FirstLastPlease make the check payable to the name provided above.PhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *NextJustification *Please explain how it fits in the curriculumStudents Affected and Benefit *Number of students that will benefit from this project and how will they benefitTotal$ 0.00Date Purchased *Date of purchaseItem #1 *Name of itemPlace of Purchase #1 *Location or website of purchaseAmount #1 *Amount paidDate Purchased #2Item #2Place of Purchase #2Amount #2Date Purchased #3Item #3Place of Purchase #3Amount #3Date Purchased #4Item #4Place of Purchase #4Amount #4Date Purchased #5Item #5Place of Purchase #5Amount #5Total Requested Refund$ 0.00Project to Credit *Fundraising Community BuildingPTA ActivitiesSchool Support OtherPlease check which project(s) to be credited. See listing below for guidance.Fundraising: Blessings-in-a-Backpack, Community Outreach, Gala, Yearbook Community Building: Back to school picnic, community socials, fall festival, volunteer appreciation PTA Activities: Health and Wellness, Odyssey of the Mind, Outdoor classroom/garden Playground, Reflections, Spelling Bee, WatchDOGS School Support: Achievement Gap, Book Fair, Gift of Learning, Mentoring, Field Day, Mini Grants for teachers Field Trip, Jamestown, Room Parent, Teacher Allocation, PBIS, Student Council Association Other: Programs, Babysitting, Other PTA Admin (please specify) Other Project (Please specify)Detailed Explanation (Activity, Event, etc.) *Explanation of Cost *Please describe how the funds will be used, or have been used for the field trip.Need By DateIf this is an advanced payment request, please enter the date when payment is needed.Certification: The expenses listed above were incurred in connection with authorized PTA work and were not otherwise reimbursed to me. Approved by:Please provide name of PTA EC member who approved this request. “President” can be listed for pre-approved categories in PTA budget.Documentation * Click or drag files to this area to upload. You can upload up to 15 files. Please upload receipt(s) or bill(s) to this form. Reimbursement will not be provided without documentation.SignatureClear SignatureSubmit