{"id":2051,"date":"2022-09-16T11:58:32","date_gmt":"2022-09-16T16:58:32","guid":{"rendered":"https:\/\/briarglenptc.org\/?page_id=2051"},"modified":"2022-09-16T12:22:28","modified_gmt":"2022-09-16T17:22:28","slug":"reimbursement-request","status":"publish","type":"page","link":"https:\/\/briarglenptc.org\/reimbursement-request\/","title":{"rendered":"Reimbursement Request"},"content":{"rendered":"<style>#kt-layout-id_388b92-ca > .kt-row-column-wrap{align-content:start;}:where(#kt-layout-id_388b92-ca > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}#kt-layout-id_388b92-ca > .kt-row-column-wrap{column-gap:var(--global-kb-gap-lg, 4rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:800px;margin-left:auto;margin-right:auto;padding-top:var( --global-kb-row-default-top, 25px );padding-bottom:var( --global-kb-row-default-bottom, 25px );padding-top:0px;padding-bottom:0px;grid-template-columns:minmax(0, 1fr);}#kt-layout-id_388b92-ca > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){#kt-layout-id_388b92-ca > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){#kt-layout-id_388b92-ca > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style>\n<div class=\"wp-block-kadence-rowlayout alignnone\"><div id=\"kt-layout-id_388b92-ca\" class=\"kt-row-layout-inner kt-layout-id_388b92-ca\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-gutter-wider kt-v-gutter-default kt-row-valign-top kt-row-layout-equal kt-tab-layout-inherit kt-m-colapse-left-to-right kt-mobile-layout-row\"><style>.wp-block-kadence-column.kadence-column_5ef8c9-4c > .kt-inside-inner-col{margin-top:0px;margin-bottom:0px;margin-right:0px;margin-left:0px;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col{padding-top:40px;padding-bottom:0px;padding-left:0px;padding-right:80px;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col{border-top-width:0px;border-right-width:0px;border-bottom-width:0px;border-left-width:0px;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col,.kadence-column_5ef8c9-4c > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column_5ef8c9-4c > .kt-inside-inner-col{flex-direction:column;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column_5ef8c9-4c{position:relative;}@media all and (max-width: 1024px){.kadence-column_5ef8c9-4c > .kt-inside-inner-col{padding-left:150px;padding-right:150px;flex-direction:column;}}@media all and (max-width: 767px){.wp-block-kadence-column.kadence-column_5ef8c9-4c > .kt-inside-inner-col{margin-right:0px;margin-left:0px;}.kadence-column_5ef8c9-4c > .kt-inside-inner-col{padding-bottom:20px;padding-left:20px;padding-right:20px;flex-direction:column;}}<\/style>\n<div class=\"wp-block-kadence-column inner-column-1 kadence-column_5ef8c9-4c\"><div class=\"kt-inside-inner-col\">\n<p class=\"has-text-align-center\">If you prefer to download a physical form to fill out, click the button below. You&#8217;ll then need to get this form to Briar Glen. Please note: This is <strong>not<em> <\/em><\/strong>an editable PDF.<\/p>\n\n\n<style>.wp-block-kadence-advancedbtn.kb-btns_01403b-ac{gap:var(--global-kb-gap-xs, 0.5rem );justify-content:center;align-items:center;}.kt-btns_01403b-ac .kt-button{font-weight:normal;font-style:normal;}.kt-btns_01403b-ac .kt-btn-wrap-0{margin-right:5px;}.wp-block-kadence-advancedbtn.kt-btns_01403b-ac .kt-btn-wrap-0 .kt-button{padding-left:20px;padding-right:20px;padding-top:10px;padding-bottom:10px;font-size:16px;margin-bottom:50px;}.wp-block-kadence-advancedbtn.kt-btns_01403b-ac .kt-btn-wrap-0 .kt-button::before{display:none;}<\/style>\n<div class=\"wp-block-kadence-advancedbtn kt-btn-align-center kt-btn-tablet-align-inherit kt-btn-mobile-align-inherit kt-btns-wrap kt-btns_01403b-ac\"><div class=\"kt-btn-wrap kt-btn-wrap-0\"><a class=\"kt-button button kt-btn-0-action kt-btn-size-custom kt-btn-style-basic kt-btn-svg-show-always kt-btn-has-text-true kt-btn-has-svg-false kb-btn-global-inherit wp-block-button__link\" download href=\"https:\/\/briarglenptc.org\/wp-content\/uploads\/2022\/09\/briar-glen-reimbursement-check-request.pdf\" target=\"_blank\" rel=\"noreferrer noopener\"><span class=\"kt-btn-inner-text\">Download reimbursement form<\/span><\/a><\/div><\/div>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading_d80dcf-d6, .wp-block-kadence-advancedheading.kt-adv-heading_d80dcf-d6[data-kb-block=\"kb-adv-heading_d80dcf-d6\"]{margin-right:0px;margin-left:0px;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;text-align:center;font-size:24px;line-height:1.5em;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading_d80dcf-d6 mark, .wp-block-kadence-advancedheading.kt-adv-heading_d80dcf-d6[data-kb-block=\"kb-adv-heading_d80dcf-d6\"] mark{font-style:normal;color:#f76a0c;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}@media all and (max-width: 767px){.wp-block-kadence-advancedheading.kt-adv-heading_d80dcf-d6, .wp-block-kadence-advancedheading.kt-adv-heading_d80dcf-d6[data-kb-block=\"kb-adv-heading_d80dcf-d6\"]{font-size:20px;text-align:center!important;}}<\/style>\n<p class=\"kt-adv-heading_d80dcf-d6 wp-block-kadence-advancedheading has-theme-palette-4-color has-text-color\" data-kb-block=\"kb-adv-heading_d80dcf-d6\">For a quicker response, submit the reimbursement form below. Eric Sedlak, the Briar Glen PTC Treasurer, will receive your request and will begin the process.<\/p>\n\n\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework gf-reimbursement-form_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' ><style>#gform_wrapper_2[data-form-index=\"0\"].gform-theme,[data-parent-form=\"2_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' 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xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2' class='gf-reimbursement-form' action='\/wp-json\/wp\/v2\/pages\/2051#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_2_14\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><h3 class=\"gsection_title\">Your contact information<\/h3><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value='' tabindex='1251'  aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value='' tabindex='1253'  aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_3\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Your phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_2_3' type='tel' value='' class='large' tabindex='1255'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><label class='gfield_label gform-field-label' for='input_2_13'>Your email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_2_13' type='email' value='' class='large' tabindex='1256'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><h3 class=\"gsection_title\">Expense details<\/h3><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' for='input_2_4'>Project \/ Category for this reimbursement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='large'   tabindex='1257'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>Detailed description of this expense<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_2_6' class='textarea large' tabindex='1258'    aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><legend class='gfield_label gform-field-label' >This reimbursement is for:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_7'>\n\t\t\t<div class='gchoice gchoice_2_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='An out of pocket expense'  id='choice_2_7_0' onchange='gformToggleRadioOther( this )'  tabindex='1259'  \/>\n\t\t\t\t\t<label for='choice_2_7_0' id='label_2_7_0' class='gform-field-label gform-field-label--type-inline'>An out of pocket expense<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='A check request to pay invoice'  id='choice_2_7_1' onchange='gformToggleRadioOther( this )'  tabindex='1260'  \/>\n\t\t\t\t\t<label for='choice_2_7_1' id='label_2_7_1' class='gform-field-label gform-field-label--type-inline'>A check request to pay invoice<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_16\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\" ><h3 class=\"gsection_title\">Reimbursement details<\/h3><\/div><fieldset id=\"field_2_8\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Check payable to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_8'>\n                            \n                            <span id='input_2_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_2_8_3' value='' tabindex='1262'  aria-required='true'     \/>\n                                                    <label for='input_2_8_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_2_8_6' value='' tabindex='1264'  aria-required='true'     \/>\n                                                    <label for='input_2_8_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' for='input_2_9'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'   tabindex='1266'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_10\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_10'>A check will be mailed to this address.<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_2_10_1' value='' tabindex='1267'   aria-required='true'    \/>\n                                        <label for='input_2_10_1' id='input_2_10_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_2_10_2' value='' tabindex='1268'    aria-required='false'   \/>\n                                        <label for='input_2_10_2' id='input_2_10_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_2_10_3' value='' tabindex='1269'   aria-required='true'    \/>\n                                    <label for='input_2_10_3' id='input_2_10_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_10_4_container' >\n                                        <select name='input_10.4' id='input_2_10_4' tabindex='1270'    aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' selected='selected'>Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_2_10_4' id='input_2_10_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_2_10_5' value='' tabindex='1272'   aria-required='true'    \/>\n                                    <label for='input_2_10_5' id='input_2_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_2_10_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_11\" class=\"gfield gfield--type-html gfield--width-full important-details gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><strong>Receipt(s) totaling the amount of reimbursement or an invoice for check request must be attached. Sales tax will not be reimbursed, so please be diligent in using the Tax Exempt Status letter when purchasing items for the PTC.<\/strong><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-fileupload gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><label class='gfield_label gform-field-label' for='gform_browse_button_2_12'>Upload your receipt(s) and\/or invoice(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_12'>You are allowed to upload jpg, gif, png, and pdf files only.<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_2_12' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_2_12&quot;,&quot;container&quot;:&quot;gform_multifile_upload_2_12&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_2_12&quot;,&quot;filelist&quot;:&quot;gform_preview_2_12&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/briarglenptc.org\\\/?gf_page=70a90353cfc9aa8&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/briarglenptc.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/briarglenptc.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf&quot;}],&quot;max_file_size&quot;:&quot;104857600b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:2,&quot;field_id&quot;:12},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_2_12&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_2_12' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_2_12' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_2_12 gfield_description_2_12\" tabindex='1273' >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_12'>Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_2_12'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_2_12' class='ginput_preview_list'><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit My Reimbursement Request' tabindex='1274' onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); 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