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 bjeszen@yahoo.com. Checks will be mailed to the address below after receiving this form and the supporting receipts/invoices.

$
Address
Address
Person Submitting Request
Name *
Name
Phone *
Phone

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.