SHORELINE BUFFER REIMBURSEMENT PROGRAM

REIMBURSEMENT FORM

Please submit this form along with a copy of your receipts to:
Holly Griffin - treasurer@branchlakeme.org - via email
or
Holly Griffin, BLAI Treasurer, PO Box 601, Ellsworth Maine 04605 - via postal mail

NAME:  ______________________________________________

Lake Address:  ________________________________________

Preferred reimbursement method (check one):   ______VENMO     ________ check

VENMO address (if requesting VENMO): __________________________________   please provide last 4 digits of phone to confirm _ _ _ _ 

Mailing Address (if requesting a check): ____________________________________

Your reimbursement will be sent within 2 weeks of receiving this request.  
Thank you for helping to keep Branch Lake Clear, Clean and Healthy!!