LTJBSA Expense Form

LJTBSA Expense Reimbursement Form

Please allow 5 days for reimbursement to be paid.
Today's Date

YearMonthDay
Date
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone
Expense Type

Advance Payment Request (if requesting LTJBSA send payment on your behalf)Expense Reimbursement
Reimbursement Method

Zelle (to phone number or email address above)Venmo (to phone number above)On LTJBSA Card (no reimbursement)Check
Reimbursement Method*

Zelle (to phone number or email address below)Venmo (to phone number below)Check (to contact below)
Pay To
Individual Name or Organization
Phone
Please enter a valid phone number
Email
example@example.com

Expenses

Receipts must show vendor name, date of purchase, and amount paid.*

Please use your camera phone to take pictures of all paper receipts for upload. If you do not include a receipt you may not be reimbursed for an expense.
Cancelof
Signature*

Clear
Summary
Expenses
Should be Empty:

LJTBSA Expense Reimbursement Form