CMEA-NS Reimbursement/Check Request
Member Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
Your E-mail Address
Reason for Request (Event, Meeting, etc.)
Check is for:
Me - Reimbursement
Other Individual
Other Organization
Other Individual Name
First Name
Last Name
Other Individual Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Name
Organization Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expense Detail
Expenses List
Rows
Purchase Date
Product/Service Description
Cost
1
2
3
4
5
Mileage Details
Rows
Mileage Date
Location/Destination
Miles
1
2
3
4
5
Total Mileage Reimbursement ($)
Total Mileage x IRS Rate 2025 (.70)
Total Check Amount ($)
Add Documentation Here (Receipts, Invoices, etc.)
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I certify that all information entered above is valid and true.
Requestor's Signature
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