ECAP Reimbursement Form

ECAP Reimbursement Form

Please attach itemized receipts and provide the totals for each vendor, supplier or contractor on this form. Please include all project costs. Total reimbursement cannot exceed the reimbursement amount approved on the Participant Agreement. If you are seeking reimbursement for more than one (1) project, please fill out a reimbursement request form for each one. Do not include more than one (1) project on a reimbursement request. Please contact oeecinfo@fairfaxcounty.gov if you have any questions about the permissible reimbursement costs.

Organization Name*

This is the name that will be included on the reimbursement check.

Mailing Address*

The address to which the reimbursement check will be mailed.

Contact Person Name*

Fairfax County staff may contact individuals for any questions about the information submitted on this form.

Phone Number for Contact Person*

Phone

Email address for Contact Person

Project Description*

Please include a short description of the approved project (e.g. energy audit, LED lights, HVAC, etc.)

Please include the number of volunteers and total volunteer hours that were involved in the implementation of the project.

Please attach a timesheet as verification if you would like volunteer hours to contribute to the total project cost and reimbursement amount.

Itemized Project Costs and Vendor Information

This section provides information on the itemized costs for the project the associated supplier, contractor or vendor used. A separate document may be uploaded if the project includes more than four (4) itemized receipts.

Supplier/Contractor/Vendor #1

Cost Item #1

Supplier/Contractor/Vendor #2

Cost Item #2

Supplier/Contractor/Vendor #3

Cost Item #3

Supplier/Contractor/Vendor #4

Cost Item #4

If you need to include additional receipts (more than 4), please upload them as a separate document when submitting this form.

Total Project Cost

Your name on this form indicates that the above information is complete and accurate.

Please upload supporting documents to include a copy of your organization's W-9.*

This includes receipts, additional itemized costs and, or volunteer timesheet as applicable.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse