VHCB AmeriCorps Reimbursement Form
To be used for reimbursement: January 2023 - December 2023; Mileage Rate: $.655 as of January 1st, 2023
Name
*
First Name
Last Name
Email Address
example@example.com
Submission Date
-
Month
-
Day
Year
Date
New Format Alert!!!
When listing the destination, please include street address (especially for your home) of start location and end location (OR title of location ie. Craftsbury Outdoor Center, O'Brien Center, etc.). Avoid writing just the name of town (ie. Winooski, Craftsbury). Forms with just towns listed will be sent back for complete address or title of location.
Mileage Calculation - Effective January 1, 2023 $.655.
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 $.655/mile. 3926-99122-391
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. 3926-99131-391
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
Should be Empty: