Reimbursement Request

Reimbursement Request

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

MonthDayYear
Name*

First NameLast Name
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

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

FuelNon-FuelAssured 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. Cancelof
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*

CheckEFT (Electronic Funds Transfer)
Bank Name:*
Bank Address:*

Street Address

Street Address Line 2

CityState / Province

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

CheckingSavings
ACH Notification E-Mail Address:*
example@example.com
My signature below signifies that I fully understand Pierce Transit Rideshare 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: