Black Village VT Submissions

Name *

First

Last

Phone *

Email *

Address

Only required for 1st submission.

What type of documentation are you submitting? *

Please confirm which documents you will be uploading. Submit a separate form for each document type.

Have you submitted a BVVT program interest form? *

Yes, Black Adult Interest
Yes, Family Interest
No, but I’d like to!
No & I’ll keep it that way for now

When will/was this purchase made or service performed?

Where did you make this purchase from?

Total Request Amount

Please highlight, circle, or otherwise make the total request amount super clear. If it’s only for certain items, please note that directly on the receipt/invoice.

Preferred Payment Info

We can do a bank check, venmo, or paypal. Cash is not an option at this time.

How would you like to receive funds?

Directly
Donate to a nonprofit in your name
Other (Please explain)

If Directly: please submit a W9 & Invoice. If Donation: please list nonprofit organization & what name you would like us to use

How many receipts/papers will you be uploading for this request?

You’ll receive the upload link in your confirmation email after you submit this request.

What kind of services/products was this for?

Meeting or Retreat Meals
Other (info below)
Gas/Uber
Parking/Tolls
Groceries
Office Supplies
Road Trip Travel Expenses (including road trip meals)
Survival Supplies (ex: tents, socks, sleeping bags)

This question is for our accounting purposes & our own ability to be transparent with how we steward our resources. It doesn’t need to be exact & definitely shouldn’t be a source of stress. It’s on this form to limit the follow up communication needed for your reimbursement.

Other: Context you'd like to offer or feel it's important we know? *

*You MUST enter clear context here to receive payment or reimbursement.

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