Updated Expense Claim and Gift-in-Kind Form

Expense Form (Reimbursements & Gifts-in-Kind)

© Mortar Board, Inc.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Purpose of Expense
Conference Travel, Meal, Supplies, etc.
Type of Expense

Please check appropriate option(s) below to: 1) DONATE a gift in kind for all/some of the expense directly to Mortar Board or 2) request REIMBURSEMENT for all/some of the expense from Mortar Board.
Type of Expense*

Gift-in-KindReimbursementBoth
Total Amount of Expense(s)*
Total Amount Incurred
Gift-In-Kind Amount

AllNoneOther
Reimbursement Amount

AllNoneOther
Details of Expense(s)

Please list the items you would like to submit for either Gift-in-Kind donations or reimbursement. Please upload receipts for each item.
Expense 1*

Description

Street Address Line 2

Date of expenseAmount

Postal / Zip Code
upload receipt

Upload a File

Cancelof
Expense 2

Description

Street Address Line 2

Date of expenseAmount

Postal / Zip Code
upload receipt

Upload a File

Cancelof
Expense 3

Description

Street Address Line 2

Date of expenseAmount

Postal / Zip Code
upload receipt

Upload a File

Cancelof
Expense 4

Description

Street Address Line 2

Date of expenseAmount

Postal / Zip Code
upload receipt

Upload a File

Cancelof
Expense 5

Description

Street Address Line 2

Date of expenseAmount

Postal / Zip Code
upload receipt

Upload a File

Cancelof
*For Reimbursements Only*

Complete section below with current mailing address if requesting expense reimbursement.
Address

Address line 1

Address line 2

CityState

ZIP
Signature of Expense Submission

I understand that to receive reimbursement, I must submit my request within 30 days of the expense. Gift-in-Kind information can be submitted at any time during the calendar year.
By my signature below, I attest 1) that this claim is accurate and represents expenses incurred by me for solely for the purposes of my volunteer work with Mortar Board and 2) that I have declared any additional personal benefit or inurement resulting from this expense for determination of its future use by Mortar Board.

My signature below signifies that I understand that I will be reimbursed after the date of the event for which the expense is claimed and that I may claim only expenses approved in advance by the National Office.
Signature*
Date

MonthDayYear
Date
Should be Empty:

Expense Form (Reimbursements & Gifts-in-Kind)

Type of Expense

Details of Expense(s)

*For Reimbursements Only*

Signature of Expense Submission

For Reimbursements Only