Reimbursement-Expense Form
Arts Ed Washington
1723 31st Ave Seattle, WA 98122
Name
*
First Name
Last Name
Submission Date
*
-
Month
-
Day
Year
Date
Available to be paid by Direct Deposit:
*
Yes
No
If not available for Direct Deposit, make check payable to:
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Rows
Travel or Purchase Date
Description/Purpose/Event (Including allocations: general operations, fundraising,
advocacy/voter information, staff/student development, community building)
..................................................................................................................................................................
Miles
Expenses
1
2
3
4
5
6
Total Miles Driven (will automatically be calculated with the current IRS mileage rate)
Mileage Rate at $0.70 per Gallon
Total Reimbursement (Mileage & Expenses)
Proof of Mileage & Receipts
*
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Instructions: Attach each receipt with date, description, purpose, and/or event; and the amount to be reimbursed. NAME is the person the check will be made payable to. SUBMITTED BY is the person completing the form. BOARD MEMBER is signatory approval from the Board Member (treasurer or executive director). All reimbursements require approval signatures from a Board Member. Board Member may sign off at each line item if there are multiple items.
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