Use the ledgers on the form below to record all payments made to your lender(s). Provide payment due amount, due date, actual payment amount, and payment date for each entry. Record the actual Amount Due as reported by your lender. Record the actual Amount you Paid. Maximum reimbursement is $400/month. Any payment made in excess of the Amount Due is not covered by NC LEAF. Notify NC LEAF if any contact information changes or if you have questions about the status of your reimbursements.HiddenQuarter Name(Required) First Middle Last NC LEAF ID Number(Required) Your NC LEAF ID Number is your NC Bar License Number with your 4 number PIN at the end (e.g. 12345-1234). If you need your PIN resent, please email us.Please select your Organization(Required)LEGAL AID OF NC EMPLOYEENC LEAFEmail Address(Required) Enter Email Confirm Email How many payments do you want to record at this time?12345678910For each Proof of Payment Submission you will need the Lender name, Amount Due, Due Date, Payment Amount, Payment Date, and a scan or screenshot of proof of payment.Record up to 10 payments below. If needed, you may return to the dashboard and make multiple submissions per quarter.PAYMENT 1Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 2Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 3Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 4Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 5Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 6Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 7Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 8Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 9Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.PAYMENT 10Lender Total Amount DueDue Date Actual Amount PaidPayment Date Upload a scan or screenshot of Proof of PaymentMax. file size: 50 MB.
