Member | Partner | Affiliate Name * Name of the entity receiving the reimbursement payment Project | Program Name * Your project | program not listed and should be? Contact nicole.watts@hopeprint.org. Northside Cultural Heritage District Mesopotamia Haven Community Garden Beakilah The Living Room Her Village Go 'Cuse Go Gulfport Hopeprint Properties Cuse Culture InfiniteTones Funding Source * The grant or funding source these expense are being reimbursed from NYS Ags & Markets National Trust for Historic Preservation Excellus Blue Cross Blue Shield Northside TNT Funds Cuse Culture Designated Funds MGCNHA Heritage Communities EPA | MS Land Trust Properties Fund Other (denote below) Other Funding Source (if applicable) Amt to be Reimbursed * If it reimbursement only includes a portion of the attached receipt, be sure to notate specifics in the notes. $ What was this receipt paying for? * Select best fit category | If for more than one category, select all and list the breakdown below Supplies | Materials Food | Beverage Contracted Services Rental Fees Utilities Insurance Printing | Postage If the receipt is for multiple categories, please list the categories below and the corresponding amount for each one. Example: Supplies - $200 | Contracted Services - $400 | Total Receipt - $600 Amt to be Reimbursed If it reimbursement only includes a portion of the attached receipt, be sure to notate specifics in the notes. $ What was this receipt paying for? * Select best fit category | If for more than one category, select all and list the breakdown below Supplies | Materials Food | Beverage Contracted Services Rental Fees Utilities Insurance Printing | Postage If the receipt is for multiple categories, please list the categories below and the corresponding amount for each one. Example: Supplies - $200 | Contracted Services - $400 | Total Receipt - $600 Amt to be Reimbursed If it reimbursement only includes a portion of the attached receipt, be sure to notate specifics in the notes. $ What was this receipt paying for? * Select best fit category | If for more than one category, select all and list the breakdown below Supplies | Materials Food | Beverage Contracted Services Rental Fees Utilities Insurance Printing | Postage If the receipt is for multiple categories, please list the categories below and the corresponding amount for each one. Example: Supplies - $200 | Contracted Services - $400 | Total Receipt - $600 Submitter's Name * First Name Last Name Submitter's Email * Amt to be Reimbursed * If it reimbursement only includes a portion of the attached receipt, be sure to notate specifics in the notes. $ Thank you!
