All requests must be supported by original receipts or invoices. After submitting this form, please email photos of the supporting receipts/invoices (in one email) to firstname.lastname@example.org. Checks will be mailed to the address below after receiving this form and the supporting receipts/invoices.
By requesting this reimbursement, I certify that:
ALL SUBMITTED EXPENSES ARE PTC-RELATED, ACCURATE, AND COMPLY WITH THE CPMS PTC REIMBURSEMENT POLICIES.
I HAVE NOT RECEIVED, NOR WILL I RECEIVE, REIMBURSEMENT FROM ANY OTHER SOURCE(S) FOR THE EXPENSES CLAIMED.
IN THE EVENT OF OVERPAYMENT, I ASSUME RESPONSIBILITY FOR REPAYING THE CPMS PTC IN FULL FOR THOSE EXPENSES.