WCFC Mileage & Expense Reimbursement Form (Non-Employee)

WCFC Mileage & Expense Reimbursement Form

Non-Employee
Name:*
Organization Name
Email Address:*
Phone Number:*
Mileage Reimbursement

Up to three trips can be entered below. Please use one section below per trip to enter information.

	Date of Travel	Travel Purpose	From	To
Travel Info for Trip 1:

	Date of Travel	Travel Purpose	From	To
Travel Info for Trip 2:

	Date of Travel	Travel Purpose	From	To
Travel Info for Trip 3:

Total Miles Traveled for Trip 3:
Total Milage Reimbursement for Trip 3:
GRAND TOTAL for Mileage Reimbursements:
Mileage reimbursement rate is calculated using current federal rate.
Meals, Travel, & Other Additional Expenses

Up to three additional expenses can be entered below (such as bridge tolls, food, other misc. expenses, etc). Please use one section below per expense to enter information. Attach any receipts necessary for reimbursement.
Date Explanation

Description for Expense 1:
Total Amount for Expense 1:
Date Explanation

Description for Expense 2:
Total Amount for Expense 2:
Expense 3:

Date Explanation

Description for Expense 3:
Total Amount for Expense 3:
Upload all receipts here.

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GRAND TOTAL for Additional Reimbursements:
Total Reimbursement & Payment Method

Please complete the form here to see total reimbursement amount and confirm your preferred payment method.
GRAND TOTAL for Mileage and Other Reimbursements:
Please sign here to verify your reimbursement request.*

Clear
Print Name:*
Date Signed:*

MonthDayYear
Date
Preferred Payment Method:*

ACHMailed CheckPayPal

	Date	Explanation
Description for Expense 1:

	Date	Explanation
Description for Expense 2:

	Date	Explanation
Description for Expense 3:

ACH Information

NOTE: If you have already provided ACH info to F5F for a prior payment, please leave section below blank and we will issue payment to the account on file. If your ACH info has changed since your last F5F payment, please include updated info below.
Name on Account:
Bank Name:
Bank Account Number:
Bank Routing Number (ABA):
Billing Zip Code:
Type of Account:

CheckingSavings

Thank you for submitting your reimbursment request!

Please allow 10-14 business days for your request to be processed.

Questions? Contact info@first5fundamentals.org or 253-682-1835.
Should be Empty:

WCFC Mileage & Expense Reimbursement Form