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Member Expense Reimbursement Form*
* Only authorized expenses accompanied by a receipt will be reimbursed except for mileage.This form must be filled out and signed by payee. Department supervisor must approve and sign form before it is submitted to Accounting.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Worksite
*
Daytime Phone Number
*
-
Area Code
Phone Number
Expenditures
Date
Vendor
Type
Description of event
Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Mileage: 2025 IRS Mileage rate is $.70/mile after 1/1/2025
Date
Purpose of travel
Starting point
Ending point
Total miles
Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL OF EXPENSES (EXPENDITURES + MILEAGE) TO BE REIMBURSED:
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: