To submit a request to the Virginia Highland Civic Association for reimbursement of expense, please print this page, and complete the form below. Please mail the completed form, along with original receipts (please retain copies), to:

Karen Page, VHCA Treasurer
952 Highland View NE
Atlanta, Georgia 30306

If you have questions, you may e-mail kpage94@hotmail.com.

Thank you!

Committee:_________________________
Budget Category:____________________

Payable to:_________________________

Address: ________________________________________

_________________________________________________

Date of Expense #1: _____________
Purpose: ______________________________________

_____________________________________________

Receipts included? yes / no

Total Amount of Expense #1: $ ________
(please attach all receipts or invoices and enter total amount above)

Date of Expense #2:_____________
Purpose: ________________________________________

__________________________________________________

Receipts included? yes / no

Total Amount of Expense #2: $ ________
(please attach all receipts or invoices and enter total amount above)