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Reimbursement Form
Reimbursement for purchases for charges using your personal funds. All purchases must be pre-approved. Please allow up to 2 weeks to process your request. You may ONLY get reimbursed during or after the mission trip and not before.
Team Name
Date
-
Month
-
Day
Year
Date
Name of the leader who approved this expense?
Mission's Location: City, State/Country
*
Your Name
*
First Name
Last Name
Your Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number
*
-
Country Code
-
Area Code
Phone Number
E-mail
*
Your E-mail Address
Local currency
*
Exchange rate relative to the dollar
*
Expenses Detailed List
Purchase Date
Product/Service Description
Cost Local Currency
COST in USD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Total from Expense list in local Currency
Total from Expense list in USD
Upload any Receipts Here
*
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How would you like to be reimbursed?
*
PayPal
Zelle
Other
Please fill in your account information of where we can send your reimbursement to:
*
Pay Pal
Zelle
If selected other please specify below your preference
In order to get refunded you must request - You can request the amount of this reimbursement in PayPay SolidRockMission@gmail.com AFTER submitting this form. If you are submitting multiple reimbursement forms please request multiple PayPal requests to match the requests.
I certify
*
I certify that all information and attached receipts have been used solely for the purpose of SRM and not for personal use. I acknowledge that I have used THE FEAR of THE LORD in making SRM transactions. I understand that by providing false information, I may be liable to repay with interest. I promise that all information entered in this form is valid and true.
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