Virginia ENA Expense/Reimbursement Form

Virginia ENA Expense/Reimbursement Form
THIS FORM MUST BE COMPLETELY FILLED OUT IN ORDER TO PROCESS YOUR REQUEST. INCOMPLETE FORMS WILL NOT BE ACCEPTED.

1. This form is to be used when requesting reimbursement of approved expenses. Reimbursements MUST be submitted WITHIN 30 DAYS of expense or travel completion.

2. Reimbursements will be done by the treasurer once the form is received with all completed paperwork. A COPY of itemized receipts must be attached for reimbursement - NO EXCEPTIONS. Receipts must be scanned, notated, and sent electronically with this form. Reimbursements are per state council procedures, please review prior to submitting.

3. Individuals must disclose if they are receiving funds or any other monies when being reimbursed by the Virginia State Council or Chapter. Pursuant to rules in the Internal Revenue Service code, persons being reimbursed are not to "personally profit" from monies received from a reimbursement.

If reimbursement is being provided by another means, please attach a copy of the reimbursement paperwork being submitted.
Are you receiving any additional/outside financial support for this reimbursement request?*

YesNo
If reimbursement is being provided by another means, please attach a copy of the reimbursement paperwork being submitted.*

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MISCELLANEOUS EXPENSES:

Please list items such as course/conference registration fees, general administration (postage, office supplies), books/manuals, misc etc.

Miscellaneous Expenses:

Total Miscellaneous Expenses:
Receipt for Miscellaneous Expenses:

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MEAL EXPENSES:

Meal allowance is up to MAX of $50 per day according to current VENA Procedures. PURCHASES OF ALCOHOLIC BEVERAGES ARE NOT REIMBURSEABLE. The meal receipt MUST be an ITEMIZED RECEIPT not just the total cost.

Meal Expenses:

	SUN	MON	TUES	WED	THUR	FRI	SAT
Date
Amount

Total Meal Expenses:
Receipts for Meal Expenses:

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TRAVEL EXPENSES:

Please list travel items such as: shuttle, baggage fees, air/train, and hotel.

Travel Expenses:

Total Travel Expenses:
Receipts for Travel Expenses:

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Mileage (Enter only the total mileage travelled. The reimbursement amount will be automatically calculated based on the current rate):

Total Miles (Roundtrip)
Total Mileage:
Map with mileage information:

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Total Expense/Reimbursement Requested:
SUBMITTED BY:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Date*

MonthDayYear
Date
Email*
example@example.com
Notes
Virginia State Council of the Emergency Nurses Association 501 (C3) Incorporated in the Commonwealth of Virginia
Treasurer and Approval Use Only:
State Debit Card Used:*

YesNo
Approver Name:*
Approver Title:*
Approval Date:*

MonthDayYear
Date
Reimbursement Method:*

Bank PayCheck
Check Number:
Amount:*
Should be Empty:

Treasurer and Approval Use Only: