Reimbursement Request Form

Reimbursement Request Form

Coach / Official / Club / Other
This form is for the reimbursement of non-travel related expenses.
Contact Information

Please provide contact information for the person making the request.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Event, Meet, Conference, or LSC Initiative
Name of the Event, Meet, Conference, or LSC Initiative*
Location
Start Date*

MonthDayYear
Date
End Date

MonthDayYear
Date
Expenses

Fill out each section that applies.

Purchased Items

	Description	Vendor	Total Cost
1
2
3
4
5
6
7
8
9
10

Purchased Items Total
Calculated Field
If purchased items exceeded $250, were multiple bids secured?

Yes, provide alternate vendors contacted in next question.No, provide explanation of no alternative bids.
Please provide details to previous question.

Travel Expenses

	Description	Total Cost
Lodging
Airfare
Ground Transportation
Tolls
Other

Mileage

	Miles
Mileage to Event
Mileage from Event

Per Diem ($40 allowance per day)
Enter number of per diem days you are claiming
Travel Expenses Total
Calculated Field

Other (Conference Registration, etc.)

	Description	Comment/Explanation	Total Cost
1
2
3
4
5

Other Total
Calculated Field
Request Total
Calculated Field
Documentation
Please provide the following documentation:

For all receipts, be sure it is a receipt and not just a credit card receipt. The receipt must show what was purchased or paid for.

Purchased Items
- Itemized receipts
Other Expenses
- Itemized receipts
Additional Documentation
- If this request is for reimbursement for travel to a conference, training, meet, etc., provide documentation of attendance.
  - Officials - screenshot from OTS
  - Others - certificate of attendance, completion, etc.
Attach all documentation. Combined to a single pdf preferred.

Cancelof
Further Explanation
Please provide any other details that may be helpful in processing your request. If asked for more information by the approver, please provide answers here.
Remittance

Please provide to whom to remit reimbursement.
Make Check Payable to:*
Send Check to:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below, you attest that all information provided in your request is true and accurate. In addition, your request is in accordance with the Bylaws and Policies and Procedures of Niagara Swimming, Inc.
Signature*

Clear
Name of Signer*

First NameLast Name
Approvals
Who Needs to Approve Your Request*

Treasurer or UnknownBusiness OfficeAdmin VCSafe SportAge GroupSenior GroupDisabilityDiversity and InclusionJr/Sr Coach RepsOfficials ChairGeneral ChairExecutive Committee
Approver Email
Auto-Filled
Should be Empty:

Reimbursement Request Form

Contact Information

Event, Meet, Conference, or LSC Initiative

Expenses

Documentation

Remittance

Approvals