Requested By:
Expense Reimbursement Form
Date Submitted:
Date Expense Incurred: Amount of Expense:
From account: Account Number: ________________
Description of Expense: Total Receipt Total Tax
REFUND AMOUNT (TAX IS NOT REIMBURSABLE):
□ Check here if you would like your check mailed to you and provide your mailing address below:
*Signature: Date:
Please attach receipts. Completed forms are to be placed in the church office mailbox.
*Tax is not reimbursable-see reimbursement policy. (please see church office if you need a tax-exempt form) I have a w-9 on file I have attached a w-9 for records $ $