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.Format: (000) 000-0000.
Email*
example@example.com
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
YesNo
How much would you like to donate?
Submitted by:*
Should be Empty: