Reimbursement Request

Reimbursement Request

Please enter the details of your reimbursement request below. Reimbursement requests must be received within 60 days of the date of purchase.
Date

MonthDayYear
Name

First NameLast Name
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List your Rideshare group ID number.
Select type of reimbursement.
Gallons of fuel purchased:
Price per gallon:
Receipts older than 60 days from the date of purchase are not eligible for reimbursement.
Provide a brief description of the non-fuel reimbursement.
Maximum car wash allowance is $40/month for washes and vacuuming.

Receipts older than 60 days from the date of purchase are not eligible for reimbursement.
List reimbursement amount (excluding tip for Assured Ride Home).
Please upload a clear photo of the entire receipt, including location, line item(s), and total.

Attachments must be no larger than 5 MB.
Cancelof
Please review the Pierce Transit Rideshare Assured Ride Home (RARH) eligibility requirements prior to submitting a reimbursement request. Preapproval is required.

Receipts older than 60 days from the date of purchase are not eligible for reimbursement.
Vehicle #
Employer/Worksite:
Date RARH taken:
Reason trip requested:
Pick up address:
Drop off address:
Other stop address, if needed:
REIMBURSEMENT OPTION
Bank Name:
Bank Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ABA Routing #
Account #
Account Type
ACH Notification E-Mail Address:
example@example.com
My signature below signifies that I fully understand Pierce Transit Rideshare Assured Ride Home Program Terms and that my use of the RARH program falls within said Terms.
Signature

This form will not be accepted without a signature.
Office Use Only
Fuel Reimbursement Code
Office Use Only
Non-Fuel Reimbursement Code
Should be Empty: