Reimbursement Request

Reimbursement Request

Please enter the details of your reimbursement request below.
Date *

Month Day Year
Name *

First Name Last Name
Email *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
List your vanpool group ID number. *
Select type of reimbursement. *

Fuel Non-Fuel Assured Ride Home
Gallons of fuel purchased: *
Price per gallon: *
Provide a brief description of the non-fuel reimbursement. *
List reimbursement amount (excluding tip for Assured Ride Home). *
Please upload a clear photo of the entire receipt, including location, line item(s), and total. *

Browse Files
Attachments must be no larger than 5 MB. Cancel of
Please review the Pierce Transit Assured Ride Home (VARH) eligibility requirements prior to submitting a reimbursement request. Preapproval is required.
Van # *
Employer/Worksite: *
Date VARH taken: *
Reason trip requested: *
Pick up address: *
Drop off address: *
Other stop address, if needed:
REIMBURSEMENT OPTION *

Check EFT (Electronic Funds Transfer)
Bank Name: *
Bank Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
ABA Routing # *
Account # *
Account Type *

Checking Savings
ACH Notification E-Mail Address: *
example@example.com
My signature below signifies that I fully understand Pierce Transit Vanpool's Assured Ride Home Program Terms and that my use of the VARH program falls within said Terms.
Signature *

This form will not be accepted without a signature. Clear
Office Use Only
Fuel Reimbursement Code
Office Use Only
Non-Fuel Reimbursement Code
Should be Empty: