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 NameLast Name
Reason for Expense*
Description of Activity/Expense

NYSATA Position or Affiliation*

	Executive Council Position	Committee Member	Other
1

Date of Activity From:*

MonthDayYear
Date
Date of Activity To:*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

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

I paid for these expenses personally, and am requesting reimbursementMy employer or other organization paid for these expenses and needs to be reimbursedThese expenses were paid for using the NYSATA cardI paid for these expenses with both personal funds & NYSATA card (put "NYSATA" in cost box for NYSATA card purchase)Other
Expense Detail

Mileage List **Mapquest/Google Maps form detailing route taken MUST be uploaded in receipts section or expense will be denied**

Expenses List

NYSATA Expense Form