Expense Reimbursement Form

Reimbursement Form

Reimbursement for purchases for charges using your personal funds. All purchases must be pre-approved. Please allow up to 2 weeks to process your request. You may ONLY get reimbursed during or after the mission trip and not before.
Team Name
Date

MonthDayYear
Date
Name of the leader who approved this expense?
Mission's Location: City, State/Country *
Your Name*

First NameLast Name
Your Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*

Country CodeArea CodePhone Number
E-mail*
Your E-mail Address
Local currency*
Exchange rate relative to the dollar*

Expenses Detailed List

	Purchase Date	Product/Service Description	Cost Local Currency	COST in USD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Total from Expense list in local Currency
Total from Expense list in USD
Upload any Receipts Here*

Cancelof
How would you like to be reimbursed?*

PayPalZelleOther
Please fill in your account information of where we can send your reimbursement to:*

Pay PalZelle
If selected other please specify below your preference
In order to get refunded you must request - You can request the amount of this reimbursement in PayPay SolidRockMission@gmail.com AFTER submitting this form. If you are submitting multiple reimbursement forms please request multiple PayPal requests to match the requests.
I certify*

I certify that all information and attached receipts have been used solely for the purpose of SRM and not for personal use. I acknowledge that I have used THE FEAR of THE LORD in making SRM transactions. I understand that by providing false information, I may be liable to repay with interest. I promise that all information entered in this form is valid and true.
Signature

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Reimbursement Form