STAFF-Reimbursement Request Form

REIMBURSEMENT REQUEST FORM

Please complete a separate form for each client and/or Halaxy Invoice
Record Number
for office to complete only
Your Name*

First NameLast Name
Client's Name
Halaxy Invoice Number/Date of Service
Total Reimbursement amount
Copy of ALL receipt/s

Cancelof
Comments
Please list the date of purchase; description of product; value (eg 26/10/2022 - weighted blanket $xx.xx)
Reimbursement to go into my regular 'pays' bank account

YESNO
Name of Bank*
Bank Account Name*
Bank Account BSB*
Bank Account Number*
ACKNOWLEDGEMENT

I'm aware I will be reimbursed
- after payment is received (ie from the NDIS or the plan manager)
- the value of the payment received (if it may be less than the submitted amount I will follow-up about this myself)
I confirm that
- these resources were obtained in good faith and for therapeutic purposes on behalf of the client/participant and with the agreement of the client/participant or their guardian.
- these resources have been given to the client/participant
I am aware that having be reimbursed for these expenses that I'm not eligible to claim them as an expense on my individual tax return.
Signature

Clear
Date*

DayMonthYear
Date
Should be Empty:

REIMBURSEMENT REQUEST FORM