Follow the steps to complete your request form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the 'Employer Name' field. Provide the official name of your employer as it appears in official documents.
3. If applicable, enter the 'Employee Name' in the designated field. This is necessary for requests made on behalf of an employee.
4. In the 'Effective Date of Request' field, input the date when you would like the reimbursement or disbursement to take effect. Ensure this date falls within the authorized service dates.
5. Proceed to the 'Total Amount Requested' section and enter the total monetary amount you are requesting. Make sure this amount is accurate and corresponds with your documentation.
6. Next, in the 'Purpose/Description' field, provide a detailed explanation of the purpose for which you are requesting the funds. This should clearly describe the expenses.
7. Attach a copy of the relevant receipt to your request form if applicable. This is important for processing your request efficiently.
8. Including your signature is crucial. The 'Employer Signature' field requires you to attest that you will use the funds solely for the listed purpose.
9. Lastly, review your form for accuracy, then save your changes, download, print, or share the completed form as needed for submission.

Submit your completed Disbursement/Reimbursement Request Form online to ensure a quick review and processing of your request.