Box 5 - Reimbursement Form

Reimbursement Form for Staff & Adjudicators
Please fill out the form below to receive your reimbursement check.
- Mileage will be reimbursed at the IRS rate, currently 65.5 cents per mile.
  - Note: The IRS periodically changes the per-mile reimbursement rate.
  - Mileage only includes the miles put on your personal vehicle while working. Transportation from your home to the worksite is considered commuting and is not to be included according to IRS regulations.
- Maximum Daily Meal Allotment (for meals not provided)
  - Breakfast – $12.00
  - Lunch - $15.00
  - Dinner - $25.00
- Please turn in all meal receipts for reimbursement.
Checks will be mailed within two weeks of receiving all receipts.
Event Name*
Bowl Game or other Event
Name*

First NameLast Name
Address to mail reimbursement*

Street Address

Street Address Line 2

CityState

Zip Code
If other than your name, what is the "pay to the order of"?
If check are written to a company name
Mileage
Date

MonthDayYear
Starting Odometer Reading
Ending Odometer Reading
Total Miles
Total Amount
Date

MonthDayYear
Starting Odometer Reading
Ending Odometer Reading
Total Miles
Total Amount
Meals
Date

MonthDayYear
Meal
Restaurant
Total Amount
Date

MonthDayYear
Meal
Restaurant
Total Amount
Date

MonthDayYear
Meal
Restaurant
Total Amount
Date

MonthDayYear
Meal
Restaurant
Total Amount
Other
Date

MonthDayYear
Please Describe
Total Other Amount
Date

MonthDayYear
Please Describe
Total Other Amount
Date

MonthDayYear
Please Describe
Total Other Amount
Reimbursement Amount
Upload Meal & Other Receipts

Choose File
You may upload multiple files Cancelof
You may also choose to print this form and mail the form and your receipts to:

BOX 5 EVENTS
532 E. ELM AVE
SALT LAKE CITY, UT 84106

* If you choose this option, please submit the form after you print.
Date of submission*

MonthDayYear
Should be Empty:

Reimbursement Form for Staff & Adjudicators

Mileage

Meals

Other