Expense Claim Form

Expense Claim Form
Date:

MonthDayYear
Date
Name*

First NameLast Name
Mailling Address*
Postal Code*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How would you like to receive your claim?*

ChequeE-Transfer
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 $0.64/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?*

YesNo
How much would you like to donate?
Submitted by:*

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Details of claim form