LP Car Travel Reimbursement Form

Local Progress Car Travel Reimbursment Form
Your First Name*
Your Last Name*
I'm filling this form out for:*

MyselfSomeone else
Traveler First Name
Traveler Last Name
Contact Information

If we need to get in touch with you about your reimbursement request we'll use this info!
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Event Details

We'll double check that you (or the traveler you're filling this out for) attended the event before we issue payment.
Event Name*
Where was the event?*
City and/or State
Mileage

We reimburse for mileage the GSA rate of 67 cents per mile for business miles driven.
Miles Driven*
Total Mileage Owed in Dollars
This field will autocalculate.
Image of Route to Destination*

This is to validate the miles driven. Please upload a PDF or image file showing a Google Map of your route to the event and the total miles driven to get there.
Cancelof
Departure Address*
Event Address*
Image of Route from Destination*

This is to validate the miles driven. Please upload a PDF or image file showing a Google Map of your route home (or wherever your post-event destination was) from the event and the total miles driven to get there.
Cancelof
Event Address*
Return Destination Address*
Tolls
I paid tolls on my trip.

YesNo
Total Tolls Paid in Dollars
Enter total dollar amount paid in tolls.
Image of Toll Receipt(s)

Please upload of a PDF or image of receipts for any tolls paid.
Cancelof
Parking
I paid for parking on my trip.

YesNo
Total Parking Paid in Dollars
Enter total dollar amount paid in parking.
Image of Parking Receipt(s)

Please upload of a PDF or image of receipts for any parking paid.
Cancelof
Payment Details

We use Bill.com to make payments securely. Learn more at www.bill.com/faq.
Total Amount Requested in Dollars
This field will autocalculate.
How would you like to be paid?*

Sign me up for direct deposit through Bill.comI need to receive a paper check and I understand this may delay my reimbursement.
I understand and acknowledge that by making this selection I authorize Local Progress and Local Progress Impact Lab to process electronic payment through Bill.com. I agree to accept the invite to create a free account on Bill.com and provide the information required to securely set-up an account. Banking information is required to receive electronic payment. I understand that while there are optional fees I can pay to receive payment faster on Bill.com, Local Progress and Local Progress Impact Lab will never require these charges for payment to be issued.

Agree
Where should we send the check?

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Who should the check be made out to?
Should be Empty:

Local Progress Car Travel Reimbursment Form

Contact Information

Event Details

Mileage

Tolls

Parking

Payment Details