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 take a clear photo of the entire receipt, including location, line item(s) and total. *
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.
After signing with DocuSign, please click the green Submit button below.
Office Use Only
Fuel Reimbursement Code
Office Use Only
Non-Fuel Reimbursement Code
Office Use Only
ARH Reimbursement Code
Should be Empty: