Expense Reimbursement Form

Expense Reimbursement Form
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Your Position*
Is this a reimbursement, check request, or to report a debit transaction?

ReimbursementCheck RequestDebit Transaction
Will a check be need for reimbursement? (answer no if you do not want to be reimbursed, but want the expense to be noted for future budgeting).*

YesNo
What name (or business) should the check be made out to?
Should the check be mailed or hand delivered?

MailedHand Delivered
Address to Mail Check*

Street Address

Street Address Line 2

CityState

Zip Code
What type of expenses are you submitting?*

Non-Mileage ExpensesMileage ExpensesBoth Non-Mileage and Mileage

Total Reimbursement for this form submission
All reimubrsements must be approved before payment is sent.

If the expense is budgeted, then the budget is your approval.

If it was not budgeted or is part of an event's expenses, approval by the Executive Committe person coordinating the event or the President is required.
Was the expense budgeted or is approval needed?*
Your signature acknowledges the amount in the "Total Reimbursement" box above is correct and that if the expense is not a budgeted expense, it may not be approved for reimbursement.
Signature*

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Approval signatures to be added after form submission, before Treasurer mails reimbursement.
Signature of President: ____________________________________ Date: ________________

Signature of Treasurer: ____________________________________ Date: ________________
Payment Details

Check Amount: ______________ Mailed Date: ________________

Check Number: ______________ Cleared Date: _______________
Should be Empty: