SC ENA Member Reimbursement Form v2

Guidelines to Reimbursement with SC ENA Standard Rules

1. No alcohol purchases will be reimbursed.

2. Maximum of $50 per day for food and non-alcoholic beverages can be reimbursed unless otherwise instructed by the SC ENA Executive Board.

3. Flights must be booked as Economy class for reimbursement. If you book another class, you must attach the round-trip economy fare on that same day. You will NOT be reimbursed for ANY flight portion if you do not include this.

4. Hotel will be reimbursed based on double occupancy. If you choose not to share a room, you will only be reimbursed for half the room rate. The hotel receipt for half of the room must be in your name – the front desk can make this happen.

5. Mileage will be based on the current National IRS Federal Rate. You must provide a Mapquest (or the like) attachment with posted mileage to/from the destination to be reimbursed. Only the primary driver will be reimbursed for mileage using their vehicle. Only the cost of the vehicle rental and fuel bills can be submitted if a rental is used. Mileage will not be granted.

6. All receipts MUST be itemized – a receipt showing the total purchase may NOT be used.

7. All receipts must be combined into ONE PDF and attached to this reimbursement form.

8. Reimbursement requests from chapters MUST attach approved chapter minutes that include the funds allotted and the name(s) of whom may be reimbursed. The names can be added as an addendum after they are known.

9. You have 30 days from the end of the event/end of travel to submit forms and itemized receipts to the treasurer through JotForm. The treasurer has 30 days to reimburse the member.

Questions? Email our SC ENA State Treasurer @ reimbursement@sc-ena.org

SC ENA Member Name*

First NameLast Name

ENA Membership Number*

I request reimbursement from the following SC ENA entity*

SC ENA Position*

Purpose for reimbursement *

i.e., conference, travel, purchase, etc.

YesNo

Travel Start Date*

Date

Travel End Date*

Date

Documentation to reimburse the SC ENA Credit CardReimbursement to myself

Phone Number*

Format: (000) 000-0000.

E-mail*

Your E-mail Address

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

Mileage Request (must enter each location - i.e., home to the event, an event to the hotel, hotel to home, etc.)

Rows	Date	Description (from-to): Private Vehicle	Mileage
1
2
3
4
5
6

Total Miles Driven

Calculated Mileage Reimbursement Amount

Upload MapQuest Directions*

YesNo

Expense List

Rows	Purchase Date	Description	Cost ($)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Expense List Calculation Total

Documents (receipts and maps) must be submitted for all reimbursement request.*

YesNo

Additional Documents (i.e., Meeting Minutes, Chapter Approval, etc.)*

Meeting minutes must be included for reimbursement that is approved for chapter members.

Amount Approved by Chapter (must match meeting minutes)*

Total Expenses*

Notes

I certify that all information entered above is valid and true.

Signature*

Membership Reimbursement Form

Travel Expense Detail(s)