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Employee Reimbursement Request
Please make check payable to:
Name: __________________________________
Address: __________________________________
__________________________________
City/State/Zip: __________________________________
EXPENSES:
Please submit this form within 30 days of incurred expense.
Date
Explanation of
Expense
Account/Purpose
Admin use only
Amount
Subtotal
$
Advance Payment Towards Expenses
$
Expenses Less Advance Payment
$
Total Reimbursement Amount
$
Please attach original receipts.
Check one to elect a contribution to {Organization Name}:
I would like to contribute the total amount to {Organization Name}.
I would like to contribute $_________ to {Organization Name}.
An acknowledgement letter will be sent to you for your donation.
Employee Signature: _____________________________________ Date: ________________
Approved by: ___________________________________________ Date: ________________
Manager of Finance and Administration
Approved by: ___________________________________________ Date: ________________
Executive Director