Expense Claim Form

Expense Claim Form
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Mailling Address
Postal Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How would you like to receive your claim?
Bank information (If this is a first time e-transfer from the diocese)
Details of claim form
If "Other" was selected for an acount code above, Please Specify
Traveled From:    . Traveled To:   . ....Kms:  . .
Traveled From:   .  Traveled To:   .     Kms:    .
Traveled From:   .  Traveled To:   .     Kms:    .
Traveled From:   .  Traveled To:   .     Kms:    .
Traveled From:   .  Traveled To:   .     Kms:.....
Traveled From:   .  Traveled To:   .     Kms:    .
Total Kms Traveled
Km rate is $0.66/km. The mileage portion of your expense reimbursement is:
Submit photos or pdfs of your receipts below

Cancelof
(OPTIONAL) Would you like to donate a portion or all of your reimbursed funds to the Diocesan Environmental Network?
How much would you like to donate?
Submitted by:
Should be Empty:

Details of claim form