Expense Form

NYSATA Expense Form

Please complete this form to request reimbursement for activities and purchases related to NYSATA business. Copies of receipts must be uploaded electronically along with this request (pdf or jpeg format). Any claimed expense not documented by a receipt may be denied. Note: You should only claim expenses approved for your activity. Not all reimbursement categories apply to all requestors. If you have any questions, please contact nysatatreasurer@gmail.com
Name *

First Name Last Name
Reason for Expense *
Description of Activity/Expense

NYSATA Position or Affiliation *

	Executive Council Position	Committee Member	Other
1

Date of Activity From: *

Month Day Year
Date
Date of Activity To: *

Month Day Year
Date
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
E-mail *
Your E-mail Address
How were these expenses paid for? *

I paid for these expenses personally, and am requesting reimbursement My employer or other organization paid for these expenses and needs to be reimbursed These expenses were paid for using the NYSATA card
Expense Detail

Mileage List

Expenses List

NYSATA Expense Form