This file must be submitted with the State Director's permission with at least 3 weeks notice of the need for remittance.

Attachment: 2309/Event_Payment_Request_Form_02062020_(fillable).pdf

1 of 2   Rev. 2/6/2020  EVENT PAYMENT REQUEST FORM (Submit this completed form to  [email protected]   at least 21 days before payment is due )  State laws limit our ability to reimburse volunteers in some states. Please obtain approval for your event before  incurring any expenses and requesting reimbursement.  Event Information   Your Information:  Name: ___________________________  State: ______________  Position: ________________  Email:  ___________________________   Phone: ____________________  Date: ____________  My COSA State Director is: ________________________________________________________  ☐ I discussed this event with my State Director, and he or she approves of this payment request. Has this event been done before & approved in the past?   ☐  Yes    ☐  No.  When? ____________  Event Name:  ______________________________________________________________________________  Event Host:  ______________________________________________________________________________  Event Description:  ______________________________________________________________________________  ______________________________________________________________________________  ______________________________________________________________________________  Event Details:  Event Date: _______________  City, State: _______________  Est. Attendance: __________  Total Cost: ________________  Have you requested a non-profit discount?    ☐  Yes    ☐  No  Check all goals  that apply:  ☐ Recruit volunteers/leaders ☐ Lobby Day at State Capitol  ☐    Respond to Opposition ☐ Educate public / seminar ☐ Meet with state legislators ☐ Conduct Simulated COS ☐ Host booth at event ☐ Collect petition signatures ☐ Other: ______________ Have you secured the necessary volunteer support for the event to be successful?   ☐  Yes    ☐  No  If you will be collecting petition signatures, what is your goal amount? ______________________  Will you be submitting a request for print materials to distribute at this event?      ☐  Yes    ☐  No  Print Media Order Form is available online at   https://conventionofstates.com/printorders     Anticipated Non-  COS Dignitaries:  ______________________________________________________________________________  Lobbying:  Will this event involve volunteers communicating with legislators or their staff?  ☐  Yes    ☐  No  Will volunteers collect petition signatures or ask citizens to contact legislators?  ☐  Yes    ☐  No      2 of 2       Rev. 2/6/2020        Itemized Budget  Cost:    Item for Purchase:  $ _____________  ______________________________________________________________________________    $ _____________  ______________________________________________________________________________    $ _____________  ______________________________________________________________________________    $ _____________  ______________________________________________________________________________    $ _____________    ______________________________________________________________________________    Payment Information    Type of Payment:    ☐    Credit Card (preferred)    ☐    Check    ☐    Wire Transfer  ☐  Other: ___________    Payment Contact:    Name: ___________________    Email: ___________________       Phone: _________________  Address:    ______________________________________________________________________________  Payment Deadline    ______________________________________________________________________________  Insurance Information  (If the event requires insurance, please complete this section and  attach a copy of the event contract .)    Venue Name:    _________________________  Date Insurance Needed:  ______________________________  Venue Address:    ______________________________________________________________________________  Venue Contact:    Name: ___________________  Email: ___________________  Phone: _________________  Additional Information    (Please provide additional information that would be helpful for COSA to consider in approving this event)    _______________________________________________________________________________________________    _______________________________________________________________________________________________    _______________________________________________________________________________________________      _______________________________________________________________________________________________      COSA Office Use Only    Date Received      _________________________    This request was submitted:   ☐  On-Time    ☐  Late  Date Approved    RD: _____________________  Legal: ___________________  Exec.: _________________  Date of Payment  _________________________        Date PEQ Rec’d:    _________________________