VHCB AmeriCorps Reimbursement Form
Form to be used for reimbursement: August 2022 - December 2022; Mileage Rate: $.625 as of July 1, 2022
Name
*
First Name
Last Name
Email Address
example@example.com
Submission Date
-
Month
-
Day
Year
Date
Mileage Calculation - Effective July 1, 2022 $.625
Date (M/D/Y)
Destination To/From
Purpose of Travel
Round Trip Mileage
1
2
3
Total Mileage
Total mileage claimed
Mileage Reimbursement
Total miles reimbursed at $.625/mile. 3925-99122-391
Expenses
Date (M/D/Y)
Description
Reimbursement Amount
1
2
Attach Expense Receipts
Browse Files
attach itemized receipts for all expenses claimed
Cancel
of
Total Expense Reimbursement
total amount of all expenses claimed. 3925-99131-391
Total Reimbursement $
Total Amount Reimbursed to Member
Member Signature
*
I certify that under the pains and penalties of perjury, that thefore going is a correct statement of the time actually spent, mileage actually and constructively traveled, and amounts necessarily incurred or paid by me in the discharge of my duties (32 VSA 464).
Submit
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