NCR REVP Bilingual Payment Request Form | Formulaire de demande de paiement bilingue RCN VPER

Supporting Documents Required | Pièces Justificatives Requises:

Individual Reimbursements: Please note that every expense submitted for reimbursement requires meeting minutes that show that the motion has passed for that particular expense, or include a passed budget for the applicable event.

Remboursements individuels: noter que chaque dépense soumise pour remboursement doit faire l’objet d’un procès-verbal de réunion qui indique que la motion a été adoptée pour cette dépense particulière, ou qu’elle comprend un budget adopté pour l’événement applicable.

Donations: require meeting minutes that reflect the passed motion with the exact amount of donation requested.

Donations: exiger un procès-verbal de la réunion qui reflète la motion adoptée et le montant exact du don demandé.

All Reimbursements: Require the completion of the fields below

Tous les remboursements : Il faut remplir les champs ci-dessous

Name | Nom *

First

Last

Person submitting the request | Personne présentant la demande

Contact e-mail | E-mail de contact *

Personal E-mail Address used for questions regarding this form | Adresse e-mail personnelle

Is this cost shared between committee's? | Ce coût est-il partagé entre des comités? *

• Yes | Oui
• No | Non

Committee(s) the expense is for | Comité(s) concerné(s) par la dépense *

• Conseil de district d’action politique de l’Outaouais (CDAPO)
• Comité régional des femmes francophones de la RCN
• Education Committee | Comité d’éducation
• Health and Safety Committee | Comité de Santé et sécurité
• Indigenous Action Circle | Cercle d’action autochtone
• Members with Disabilities Access Committee (MDAC) |
• Comité accès des membres ayant un handicap (CAMH)
• Ottawa Area Council (OAC)
• Ottawa Regional Women’s Committee (ORWC)
• Pride Committee | Fierté
• Racialized Members’ Action Committee (RMAC) | Comité d’action des membres racisés (CAMR)
• Young Workers Committee (YWC) | Jeunes travailleurs
• Inter-Committee Funds | Fonds intercomités

Only select more than one when cost sharing | Sélectionnez plus d’un comité uniquement en cas de partage des coûts.

Expense Type | Type de dépense—Invoice (to be paid by REVP office) | FactureReceipt (to be reimbursed to member by cheque) | ReçuHonorarium to an Elder/Speaker (to be paid by REVP office) | HonorairesDonation (to be paid by REVP office) | Don|Taxi Chit Used | Bon de taxi utilisé

Purpose of the Expense | But de la dépense…Committee SwagCommittee Meeting ExpenseCommittee DonationCommittee TrainingCommittee EventCommittee MiscIntersectional Committee Funds

Describe the reason for the spending. Décrire la raison du fonds

Make Payable To | Rendre payable à *

Please write the correct full name of the payee. Any mistake will delay request process. Veuillez écrire le nom complet du bénéficiaire. Toute erreur retardera le processus de demande.

Confirm Mailing Address of Payee | Confirmation de l'adresse postale du bénéficiaire *

Address Line 1

City

State / Province / Region

Postal Code

— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Please write the correct full address of the payee. Any mistake will delay request process. Veuillez indiquer l’adresse complète du bénéficiaire. Toute erreur retardera le processus de demande.

Please provide Expense Breakdown between committee's

Total Amount Requested | Montant total demandé *

One form per payee. Un formulaire par bénéficiaire.

Minimum Price: $10.00

Spending Authority | Autorisation de dépenser—Motion passed | Motion adoptéeCommittee Chair (can only be selected if the Chair is submitting the expense) | Président du comité

Please attach *PDF * of minutes/ROD to the request if a motion passed. Veuillez joindre le procès-verbal/ROD à la demande si une motion a été adoptée.

I acknowledge that this is an attestation that the funds were spent under bylaw…. *

• Agree

Motion – Minutes | Motion – Procès-verbal *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload the approved meeting minutes with the motion indicating the approved expense.

Receipt | Reçu—I have a receipt | J’ai un reçuI will upload an attestation | Je vais téléverser une attestation

Attestation | Justificatif

Drag & Drop Files, Choose Files to Upload

Upload the Receipts *PDF* | Téléversez les reçus

Drag & Drop Files, Choose Files to Upload

All expenses must have a receipt attached. Tous les frais doivent être accompagnés d’un reçu.

Additional Supporting Documents | Documents complémentaires

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

Committee Email | Courriel du comité *

Special Instructions | Instructions spéciales

Please include website where applicable ( ex. Donations) | Veuillez inclure le site Web, s’il y a lieu (p. ex., pour les dons).

Is there a deadline for payment? | Y a-t-il une date limite de paiement?—Yes | OuiNo | Non

Why is there a deadline for payment? Pourquoi y a-t-il une date limite de paiement?

Date & Time payment required by (2 weeks minimum is required to process all requests for payments via cheque)

Date

Time

Submit