Imperial Court Check Request
Imperial Court
Check Request Form
CHECK REQUEST MUST BE SUBMITTED WITHIN 30 DAYS OF EVENT
Date:
*
/
Month
/
Day
Year
Department:
Purpose:
*
Name:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Itemize all expenses to be reimbursed on this request.
**** NO REIMBURSEMENT WITHOUT RECEIPTS. RECEIPTS MUST BE UPLOADED TO THIS FORM. ****
Number of Days:
(Enter the total days including travel days)
Per Diem:
( Per Diem ($65) x No. of Days)
Total Per Diem:
Airline Ticket:
(Upload Receipt)
Lodging:
(Upload Receipt)
Rental:
(Rental car reimbursement does not include any mileage)
Mileage (Personal Auto):
(Miles x $0.76 per mile - calculated below ) - Google Maps acceptable as mileage receipt
Miles x $0.76 per Mile
Gratuities:
Parking & Tolls:
(Upload Receipts)
Local Transportation:
(Taxi, Uber, Lyft - Upload Receipts)
Printing:
(Upload Receipts)
Postage:
Donations:
Supplies:
(Upload Receipts)
Other Expenses:
(Upload Receipts)
Total Reimbursement:
Payment Method:
*
Select Payment:
ACH
Mail Check
Upload Files:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Requester:
*
Signature:
*
Submit
Should be Empty: