Expense Reimbursement Form
Updated April 2023
Employee name
*
Employee Email
*
Date submitted
*
/
Month
/
Day
Year
Date
Funds to be taken from
*
Area/Base, Personal Reserves, Support Services, etc
Send funds via:
*
Direct Deposit (to account on file)
Mailed check (to address on file)
Supervisor Email
*
While in initial fundraising: support coach When in ministry position: manager
Supervisor Signature
Finance Email
*
This field is automatically filled. Change only if necessary.
Finance Signature
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Transportation
Line 1
Date 1
-
Month
-
Day
Year
Date
Destination 1
Purpose 1
Miles 1
Transportation Line 2 (if applicable)
Date 2
-
Month
-
Day
Year
Date
Destination 2
Purpose 2
Miles 2
Transportation Line 3 (if applicable)
Date 3
-
Month
-
Day
Year
Date
Destination 3
Purpose 3
Miles 3
Transportation Line 4 (if applicable)
Date 4
-
Month
-
Day
Year
Date
Destination 4
Purpose 4
Miles 4
Transportation Line 5 (if applicable)
Date 5
-
Month
-
Day
Year
Date
Destination 5
Purpose 5
Miles 5
Transportation Totals and Calculations
Total Miles
Per Mile Charge
Defaults to the current IRS standard rate
Total Mileage Reimbursement
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Other Expenses
Date A
-
Month
-
Day
Year
Date
Store/Venue A
Purpose A
Amount A
Other Expenses Line B (if applicable)
Date B
-
Month
-
Day
Year
Date
Store/Venue B
Purpose B
Amount B
Other Expenses Line C (if applicable)
Date C
-
Month
-
Day
Year
Date
Store/Venue C
Purpose C
Amount C
Other Expenses Line D (if applicable)
Date D
-
Month
-
Day
Year
Date
Store/Venue D
Purpose D
Amount D
Other Expenses Line E (if applicable)
Date E
-
Month
-
Day
Year
Date
Store/Venue E
Purpose E
Amount E
Other Expenses Line F (if applicable)
Date F
-
Month
-
Day
Year
Date
Store/Venue F
Purpose F
Amount F
Other Expenses Line G (if applicable)
Date G
-
Month
-
Day
Year
Date
Store/Venue G
Purpose G
Amount G
Transportation Totals and Calculations
Total Other Expenses
Total Reimbursement
Submit Receipts
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For all mileage and other expenses
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