Expense & Reimbursement Request Form
Name (as you want it to appear on a check) Scholarship recipients, please list YOUR name here.
*
First Name
Last Name
Address (where payment will be sent). Scholarship recipients, this should be the address for the bursars office at college
*
Street Address
Street Address Line 2
City
State
Zip Code
Email
*
example@example.com
Phone Number
*
In case we need to contact you
Format: (000) 000-0000.
Type of Expense
*
Please Select
Airfare & Baggage Fee
Hotel
Meals
Mileage (see IRS.gov for current rates)
New Official Expense
Office Supplies
Office Equipment
Scholarship Recipient - Funding Request
Swim Meet - Officials
Swim Meet - Admin or Staff
Swim Meet - other
Date of the Expense
-
Month
-
Day
Year
Date
TOTAL Amount requested - ATTACH COPIES OF RECEIPT(S) BELOW. Scholarship Recipients, please include a copy of your WSI scholarship notice.
*
How did you pay for your item?
Credit Card
Cash/Check
Description or explanation for reimbursement. Scholarship recipients, please include YOUR address, email and phone here PLUS the university/college name and your account number, if known.
*
Upload related documents/receipts. Receipts are required for all reimbursements.
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