Match Official Reimbursement Request

Match Official Reimbursement Request
BALMAIN & DISTRICT FOOTBALL CLUB

Manager Reimbursement Request Form
1. Retain all Match Official Payment Forms (note: signed matchsheets are NOT acceptable evidence of paid match officials.
2. Ensure you keep copies of all documents until you have received reimbursement.
3. Reimbursement Requests will only be accepted when supported by signed Match Official Payment forms.
4. Reimbursement Requests will be processed monthly - please do not submit requests after each individual match.
5. Each reimbursement claim can accommodate upto six matches. To claim for more than six matches, simply submit additional forms.
6. Reimbursement Requests for matches taking place prior to 31 August 2019 must be submitted by 30 September 2019. Reimbursement Requests for matches taking place after 31 August 2019 must be submitted by 30 November 2019. Late submissions will not be accepted.
NO EXCEPTIONS TO THE ABOVE WILL BE ENTERTAINED

Match officials' fees are a significant expense for the Club and must be well managed and auditable.
Team & Manager Details
Age Group *
Enter team age group
Team (Division) *
Enter Division and Team Designation (eg 1A, 4B etc)
Manager Name *

First Name Last Name
Phone Number *

- Area Code Phone Number
E-mail *
Bank Account to be Reimbursed
Account Name *
Name of account reimbursement is to be credited to
Bank Name *
BSB *
Enter as a six digit number with no hyphen
Account # *
Match Official Rates
*

Referee $15 / Assistant $5 (U10 - U11) Referee $20 / Assistant $10 (U12 - U14) Referee $25 / Assistant $15 (U15 - U16) Referee $30 / Assistant $15 (U17 - U18) Referee $35 / Assistant $17 (U21, WIL, AA, O35, O45) Referee $40 / Assistant $20 (BBC / GMT)
Match Details & Amount Claimed
Claim 1
Round # *
Date of Match *

- Month - Day Year
# of Referees *

0 1
# of Assistants *

0 1 2
Total Paid for Claim 1 $ *
Enter in whole dollars, no decimal places
Do you wish to add another round? *

Yes No
Claim 2
Round #
Date of Match

- Month - Day Year
# of Referees

0 1
# of Assistants

0 1 2
Total Paid for Claim 2 $
Enter in whole dollars, no decimal places
Do you wish to add another round?

Yes No
Claim 3
Round #
Date of Match

- Month - Day Year
# of Referees

0 1
# of Assistants

0 1 2
Total Paid for Claim 3 $
Enter in whole dollars, no decimal places
Do you wish to add another round?

Yes No
Claim 4
Round #
Date of Match

- Month - Day Year
# of Referees

0 1
# of Assistants

0 1 2
Total Paid for Claim 4 $
Enter in whole dollars, no decimal places
Do you wish to add another round?

Yes No
Claim 5
Round #
Date of Match

- Month - Day Year
# of Referees

0 1
# of Assistants

0 1 2
Total Paid for Claim 5 $
Enter in whole dollars, no decimal places
Do you wish to add another round?

Yes No
Claim 6
Round #
Date of Match

- Month - Day Year
# of Referees

0 1
# of Assistants

0 1 2
Total Paid for Claim 6 $
Enter in whole dollars, no decimal places
The maximum number of claims that can be submitted at one time is six. To submit more claims please complete and submit a new form.
Total Amount to be Paid $
Please ensure that the above amount is correct before submission.
Upload Signed Match Official Payment Form *
Only claims supported by signed Match Official Payment Forms will be paid.
Comments
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Match Official Reimbursement Request

BALMAIN & DISTRICT FOOTBALL CLUB

Team & Manager Details

Bank Account to be Reimbursed

Match Official Rates

Match Details & Amount Claimed

Claim 1

Claim 2

Claim 3

Claim 4

Claim 5

Claim 6