Referee Reimbursement Request Form

Referee Reimbursement Request Form
Ashfield Pirates FC

Reimbursement Request Form
1. Fill in the Referee Reimbursement form and use as 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 sheets.
4. Reimbursement Requests must be submitted at the end of each month and will be processed monthly - please do not submit requests after each individual match.
5. Each reimbursement claim can accommodate up to 4 matches. To claim for more than 4 matches, simply submit additional forms.
6. Reimbursement Requests for matches taking place prior to the 04th October 2021 must be submitted by no later than the 30th November 2021. 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 (e.g. U12, AA, BBC)
Team Division *
Enter team Division & designation (e.g. 1A, 5B)
Manager Name *
Enter First & Last name
Contact Number *
Mobile number
Email Address *
BANK ACCOUNT TO BE REIMBURSED
Account Name *
Name of account reimbursement is to be credited
Bank Name *
BSB *
Enter as a six digit number with no hyphen
Account Number *
MATCH OFFICIAL RATES
Age Group Selection

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 # *
Total Paid for Claim 1 $ *
No decimal places
Number of Referees *

0 1
Number of Assistants *

0 1 2
Claim 2
Round #
Total Paid for Claim 2 $
No decimal places
Number of Referees

0 1
Number of Assistants

0 1 2
Claim 3
Round #
Total Paid for Claim 3 $
No decimal places
Number of Referees

0 1
Number of Assistants

0 1 2
Claim 4
Round #
Total Paid for Claim 4 $
No decimal places
Number of Referees

0 1
Number of Assistants

0 1 2
Total Amount to be Reimbursed $
No decimal places
Claim 5
Round #
Total Paid for Claim 4 $
No decimal places
Number of Referees

0 1
Number of Assistants

0 1 2
Total Amount to be Reimbursed $
No decimal places
Please ensure that the above amount is correct before submission.
Upload Team Sheet *

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Only claims supported by signed Official Match Sheet will be paid.
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Referee Reimbursement Request Form

Ashfield Pirates FC