Volunteer Reimbursement Form

Name*

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Event/Project Name*

Event Date*

Mileage Expenses?*

Yes
No

Applicable to personal vehicle use only. Only the owner of the vehicle driven is eligible to submit miles to be reimbursed. Miles should reflect the most direct route. Reimbursement = $.60/mile

Miles Driven

Rental Car Expenses?*

Yes
No

Total Rental Car Expense*

Pre-Authorization is required. Must include a rental car receipt. These amounts are all inclusive and will not include mileage reimbursement.

Rental Car Receipt*

Max. file size: 256 MB.

Please refer to the Employee Handbook for amounts to be reimbursed and reimbursement policies. If you have trouble attaching your receipt please email a copy to office@psia-w.org

Airfare Expenses?*

Yes
No

Total Airfare Expense*

Pre-Authorization is required. Must provide airfare receipt.

Receipt for Airfare*

Max. file size: 256 MB.

Please refer to the Employee Handbook for amounts to be reimbursed and reimbursement policies. If you have trouble attaching your receipt please email a copy to office@psia-w.org

Lodging Expenses?*

Yes
No

Total Lodging Expense*

Must provide a receipt for lodging to be reimbursed. Reimbursement of $60 per night for double room occupancy; $100 per night for single room occupancy. These amounts are all inclusive. If lodging is provided, reimbursement for lodging will not be approved.

Receipt for Lodging*

Max. file size: 256 MB.

Please refer to the Employee Handbook for amounts to be reimbursed and reimbursement policies. If you have trouble attaching your receipt please email a copy to office@psia-w.org

Any other expenses?*

Yes
No

All other expenses will go through an approval process before being reimbursed. Please provide receipt documentation for any additional expense.

Explanation and amount of additional expenses*

Receipts for Additional Expenses*

Max. file size: 256 MB.

If you have trouble attaching your receipt please email a copy to office@psia-w.org

Signature

Reimbursement Form

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