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

Rows	Executive Council Position	Committee Member	Other
1

Date of Activity From:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Activity To:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?

Other
Expense Detail

Mileage List -_ - _ - _ - _ -_-_ - _ - _ - _ - _-_ - _ - _ - _ -_-_ - _ - _ - _ - _ - _ - _ -*If selecting "Yes" for "Round Trip?" Put the combined mileage for both trips in "Total Miles"* -_ - _ - _ - _ - _ -_ - _ - _ - _ -_-_ - _ - _ - _ - _-_ - _ - _ - _ -_-_ - _ - _ - _ - _ - **Mapquest/Google Maps form detailing route taken MUST be uploaded in receipts section or expense will be denied**

Rows	Travel Date	Destination	Total Miles	Round Trip?
1
2
3

Total Miles Driven

Expenses List

Rows	Purchase Date	Description	Cost
1
2
3
4
5
6
7
8

*Please add description if you selected "other" above
Total from Expense list
Total Amount Due from Mileage ($0.65/mile)
Total from Expense List and Mileage
I certify
Upload any Receipts Here

Browse Files

Cancelof
Please verify that you are human
Signature
Should be Empty:

NYSATA Expense Form

Expense Detail