REIMBURSEMENT FORM2023-11-01T12:36:29-07:00


Prior to requesting reimbursement, your business must have received preauthorization prior to the purchase.

Items eligible for reimbursement include sustainable alternatives such as compostable, fiber-based, or reusable to-go containers, to-go utensils, one-time use straws, and innovative to-go one-time use edible utensils like spoons for ice cream. By submitting this form I understand and agree that reimbursement, if any, is subject to City’s review and sole and reasonable discretion; is subject to available funding, if any; and in submitting said form, agree that City has made no representations or warranties, expressly or otherwise, that funding is in any way guaranteed; and if City discovers or is made aware of any false or inaccurate statements or information provided City regarding eligibility of reimbursement, the facility shall immediately return any monies provided by City, and be subject to repayment of City’s reasonable costs towards such efforts. I further consent to provide and allow the City to the use of the facility’s name, its location (city and state), and photographs, or other pictorial representations of the facility (including, without limitation, logos, seals, marks, and architectural features of facility) for purposes of advertising online and in print or any other media or trade in connection with the program or City’s promotion of its services, without further compensation of any kind. The City further reserves the right to use any and all information related to the program for marketing purposes or any other purpose, unless prohibited by law. By submitting the form, you understand and agree that you are disclosing certain information to the City which may be used as set forth herein, and subject to disclosure in accordance with applicable law, including but not limited to, the California Public records Act (California Government Code Sections 7920 et seq.

Provide signed W-9, receipts or invoices with proof of payment, to the reasonable satisfaction of City.

By signing this reimbursement request, I declare under penalty of perjury under the laws of the State of California that the facility has satisfied the eligibility requirements, that all information and documents provided to the City are true and correct, and that the forgoing is true and correct, that I have full authority to act on behalf of the above named facility, and agree to indemnify, defend, and hold City harmless from any claims and/or liability related in any way to participation in the program.
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