Name:

Email Address:

Telephone Number:

First & Last Name

Complete Mailing Address: Street Address, City, State & Zipcode

Did you make a purchase? Did you transport the Reins of Hope trailer? Did you volunteer the use of your horse for Sessions? Did you transport horses for use during a Reins of Hope Session?

Single Purchase or Multiple Purchases?

Date of Purchase?

List Dates of Purchase and description of items.

Description of items purchased

One Transport or Multiple Transports?

Date of Transport?

List the Dates and Reason for the transportExample

Reason for Transport?Examples

How many personal horses were utilized during Reins of Hope Sessions?

How many sessions was your horse utilized for?

List the Name(s) of your Horse(s)

Single Transport or Multiple Transports?

What date did you transport horses?

List the Dates you transported horses for use during Reins of Hope Sessions

Total Reimbursement Amount Requested