WSSRA

Washington State School Retirees Association

PO Box 5127 Lacey WA 98509 360-413-5496
First Name   Last Name    Area Code      Phone Number

Street Address      City   State   Zip

Check here if change of address    Yes
Email
example@example.com
Please select your Unit Name and Number
PLEASE SELECT YOUR BUDGET: WSSRA staff will call chair for approval if signature is required to charge to committee budget. *

Mileage Reimbursement:

	Date (M/D/Y)	Destination	Travel Details or meeting attended	Round Trip Miles
1
2

Total Round Trip Miles:
Total Round Trip Miles X current rate (.70)

Meals & Hotel: (Please enter in Dollar amount)

	Bkfst	Lunch	Dinner	1 night Hotel
1.

Total for Meals & Hotel reimbursement:

Miscellaneous Expenses:

	Printing	Postage	Misc.	Description/Explanation
1
2

Total Misc. Expenses:
TOTAL REIMBURSEMENT (Meals, Hotel, Misc. and Mileage)
IF YOU HAD ADDITIONAL PARTICIPANTS FOR TRAVEL OR MEALS PLEASE LIST THEM
attach PDF or JPG file of your receipts here.

Browse Files

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I certify that this statement, the amounts claimed, and attached receipts represent necessary expenses incurred by me while engaged in the Association's business.
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