Reimbursement Request Form

Today's Date

Is this an Expense Reimbursement or a Mileage Reimbursement?

Expense Reimbursement RequestMileage Reimbursement RequestBoth

First Name

Make check payable to ________

Last Name

Address where reimbursement check should be sent

Supervisor's name

Supervisor's Email

If you have multiple receipts, please submit one Reimbursement Request Form per receipt.

Expense Reimbursement (do not include sales tax)

Staff are encouraged to use their company credit cards for all purchases. If a purchase must be made without a company credit card, the following information can be filled out to request a reimbursement.

Date of Purchase

Store

Which program was this purchase for?

If "Other," please describe:

What location was this purchase for?

Item(s) Purchased

Amount

Please no "$" sign

Please upload an image of your receipt

Mileage Reimbursement

Staff, Interns, and VISTAs who use their personal car to drive for agency reasons can request mileage reimbursement. Travel from home to work does not qualify for reimbursement. If your starting location is from home, you'll need to take out the round-trip distance from your home to your typical work location.

Staff Site

Staff Program

If "Other," please describe:

Travel Details

Date of Travel

Reason for Travel

Starting Location

Next Location

If Applicable, Next Location

Total Miles Driven This Trip (minus distance from home to work if applicable)

For 2024, the mileage reimbursement rate is $.67 per mile. If your request is approved, you will receive the following amount for this trip

If you need to record another trip for mileage reimbursement, please select 'add another response' below.

Expenses Total (Auto-Filled):

Mileage Total (Auto-Filled):

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