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

Attachment: 2309/EventPaymentRequestForm02062020(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 \\ \\ \\ \\ {{:public:cb_mirror:files_7255_pdfto002.png?nolink&918x1188|}}\\ \\  \\ \\  \\ \\ 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: \\ \\  \\ \\ %%_   

 

| | —- | Page Metadata || |Login Required to view? |No | |Created: |2018-10-23 13:55 GMT| |Updated: |2021-06-21 16:39 GMT| |Published: |2018-10-23 13:56 GMT| |Converted: |2025-11-11 12:12 GMT| |Change Author: |Joanne Laufenberg | |Credit Author: | |