Arlington Regia
Reimbursement Request

Legion of Mary
Arlington Regia

Reimbursement Request
Date submitted:	_________________	Function_____________________

    	Date_______________
Name	_________________________________________

Address 	_________________________________________

City/ST/zip	_________________________________________

Phone	_________________	email ____________________________

Enter amount for each itemized receipt. If receipt is not itemized, please detail here.

1	___________________ 
2	___________________ 
3	___________________ 
4	___________________ 
5	___________________ 
6	___________________ 
7	___________________ 
8	___________________ 
9	___________________ 
	10	___________________ 

Reimbursement

Total $		

STAPLE or TAPE receipts to this page.