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 Amel's Hope FAHNN Bare Roots Festival 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 Boeheim Grant CNYCF Community Grant 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!
