Clay Leadership Development Grant and Circle Grant Report and Reimbursement

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COMPLETE THIS FORM: To receive a reimbursement for your program supported by a Clay Grant, Endowed Circle Grant, or Restricted Circle Grant, complete this form and attach PDF copies of receipts for actual expenses accrued. If you have any questions about the reimbursement process, contact Jamie Bouldin ([email protected] | 540-458-5348).

DEADLINE FOR REIMBURSEMENTS: Grant funds are available from January 1 to December 15. Reimbursements must be submitted by December 15 of the year in which your program takes place.

Institution Name

Select Grant Type

Clay Leadership Development Grant
Endowed Circle Grant
Restricted Circle Grant

Your Name

First

Last

Your Email

Reimbursement Amount Requested

Please note: Grants are awarded for actual expenses up to the amount approved in the grant paperwork. Please verify your maximum amount before submitting this form. Your submitted receipts should add up to the total amount approved for reimbursement. If the receipts are for more than the approved, only the approved amount will be reimbursed.

Make the Check Payable to:

Please insert the specific name of the institution or individual to whom the payment should be addressed. If this is a circle private bank account, it is helpful if you attach a voided check or deposit ticket so we can include that account number on the check.

To": Check Media

Send check "Attention To":

Mailing Address for Payment

Address Line 1

Address Line 2

City

State

Zip Code

Please make sure that any office numbers or campus PO boxes are included if necessary for efficient receipt of payment.

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