Expense Reimbursement Request

By: Date:
From: (name of agency):

I. Please indicate purpose of expenses by checking below, indicating DATES where appropriate.
 Administrative expenses as follows:

Full Meeting  Ex. Com.    Sub. Com    CCOM/PEP
Tel/Mail        Dues/Mtgs. Training      Interpret.
Program expenses as follows:
Planning         Materials    Leadership
Prom./Reg.     Housing     Food            Other
II. Documentation:
Travel from: to
Miles Traveled: x  (Please enter total mileage fees in the box to the right)                           $
Breakfast (Not to exceed $7.00): $
Lunch (Not to exceed $13.00): $
Dinner (Not to exceed $20.00): $ (Please enter total meal fees to the box to the right) $
days @ $ (Please enter lodging fees to the box to the right) $
Total Expenses: $
For Office Use Only
Verified by____________________________
Payment Authorized by ______________________
Voucher No. __________________________
Posted to Account No. __________________
Sub No.______________________________


Note: Please fill out and print one of these expense forms for each trip and attach all meal, hotel and motel bills. The request will presented to the Conference Treasurer.  Be sure that your total expenses have added correctly, use tab key to move between fields.