Reimbursement Form

Name: Address: City: State: Zip:

Clearin# an advance Re,uestin# an advance 'pecial instructions below

Complete all information. Incomplete forms will result in delays. !ri#inal itemi/ed bills or receipts must be attac$ed for 041 all airline fares, 051 all lod#in#, 061 all medical expenses, and 071 all sin#le expenditures of $89 or more. 3! !" ( C*!'( R(C(I)"' & *('' R(:&IR(3.

Period Covered: !" daily commutin# costs.

1. Transportation, Parking, Tolls

Air, bus, taxi, driver, etc. Ministry related only,

1. 2. . ". $. &.
(. *.

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

2. Meetings and Retreats

Re#istration and tuition for ministry meetin#s, trainin# meetin#s.

. Corresponden!e
"elp$one ministry calls, prayer letters, posta#e, printin#, etc. Ministry %&'I ('' )&R)!'( ! *+. For current per diem rate, see rate c$art. (xpenses $. %odging Complete ot for movin#. Receipt re,uired. 'c$edule

". Meals and Per #iem

&. C'ild!are

For ministry meetin#s, trainin# and retreats only.

(. S)pplies and Materials

!nly items for ministry wor- may be reimbursed. *ist on bac-.

*. Mis!ellaneo)s
(xplain.

+. S)m o, lines ( and * 1-. Reim.)rsa.le Claims

As indicated on insurance co. wor-s$eet. Medical 11. Ann)al p'ysi!al, dental, vision, 'earing !are and ot'er. Attac$ Receipts. (xpenses 1-. 11.

+.

$0.00

12. S)m o, lines 1- and 11 1 . Nonta/a.le Co)nseling 1". 1$. Auto Complete 1&. 'c$edule 1(. 1*.
'alary

12. 1 . 1". 1$. 1(. 1*. 1+. 2-. 21. 22. 2 . 2". 2$. 2&. Take Ta/a.le: Take Non1Ta/a.le: Advan!e:

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Ministry A)tomo.ile 6/pense 0From 'c$edule C;91 Personal A)tomo.ile 6/pense 0From 'c$edule C;<1 A)to P)r!'ase Sales Agreement is: Ministry A)to P)r!'ase 0From 'c$edule 3;51 Personal A)tomo.ile 6/pense 0From 'c$edule 3;61

1+. Additional Salary 0(nter total bein# claimed1 2-. Ta/ Allo7an!e 0'um of lines 49, 4=, 4>; multiplied by t$e appropriate rate1 21. 0a!k Pay

Movin# 22. Moving: Minim)m $ miles. (xpenses Include receipts and itemi/e 0transporation, lod#in#, meals, auto milea#e, #asoline, etc1 Advance 2 . Reim.. Advan!e )urpose.

"otal

2". S)m o, lines 112 2$. Amo)nt o, reim.)rsement advan!e to .e !leared.

$0.00

2&. 2rand Total 3line 2$ s).tra!ted ,rom line 2"4

Spe!ial 5nstr)!tions:
ote.

$0.00
$0.00 $0.00 $0.00

'taff Member 'i#nature2222222222222222222222222222222222222222222 Approval 'i#nature22222222222222222222222222222222222222222222222

3ate2222222222222 3ate2222222222222

Itemi/ation of all claimed expenses

Category 3line no.4:
1. Transportation, Parking and Tolls

#ate:

Amo)nt:

5tem 8 9or :'om 8 Ministry A!tivity 5nvolved

2. Meetings and Retreats

. Corresponden!e

". Meals and Per #iem

$. %odging

&. C'ild!are

(. S)pplies and Materials

*. Mis!ellaneo)s

Itemi/ation of all claimed expenses

Category 3line no.4:
1. Transportation, Parking and Tolls

#ate:

Amo)nt:

5tem 8 9or :'om 8 Ministry A!tivity 5nvolved

2. Meetings and Retreats

. Corresponden!e

". Meals and Per #iem

$. %odging

&. C'ild!are

(. S)pplies and Materials

*. Mis!ellaneo)s

Itemi/ation of all claimed expenses

Category 3line no.4:
1. Transportation, Parking and Tolls

#ate:

Amo)nt:

5tem 8 9or :'om 8 Ministry A!tivity 5nvolved

2. Meetings and Retreats

. Corresponden!e

". Meals and Per #iem

$. %odging

&. C'ild!are

(. S)pplies and Materials

*. Mis!ellaneo)s

Automobile (xpenses and (xtra 'alary

Automobile Maintenance and !peration
C;4. Calculate Milea#e and )ercenta#es
(nter ministry milea#e. (nter )ersonal milea#e. "otal. 0 )ercenta#e Ministry Miles. )ercenta#e )ersonal Miles. "otal. 0.00? 0.00? 0.00?

*ist wee-ly totals below

C;5. @as, !il, *ube, Aas$
3ate Amount 3ate Amount

C;6. Repairs, )arts, Insurance, Re#, etc.

3ate Amount Item

C;5 "otal.

$0.00 $0.00 $0.00 $0.00

C;6 "otal.

$0.00

C;7 0"otal Auto (xpenses1. C;9 0Ministry Auto (xpenses1. C;< 0)ersonal Auto (xpenses.1.

Automobile )urc$ase
3;4 0"otal Amt. %ein#
0'ales a#reement must be on file in accountin#1 (nter t$e total amount you are claimin# on t$is Claimed1. $0.00 reimbursement.

3;5 0Ministry )urc$ase Amt1. 3;6 0)ersonal )urc$ase Amt1.

$0.00 $0.00

3;5 B 3;4 C C;4 Ministry ? 0Inserted on line 481 3;6 B 3;4 C C;4 )ersonal ? 0Inserted on line 4=1

Additional 'alary
Includes settlin# in, plannin# wee-ends, expenses for c$ildred. *ist dates and expenses below. "otal inserted on line 4>.
)lannin# Aee-end 'ettlin# In 'pecial eeds 'alary !t$er; (xplain %elow

3ate

Amount

Item, 3escription, )urpose

Automobile (xpenses; )er Mile

C1$ A)tomo.ile Mileage Reim.)rsement
3ate Milea#e Ministry activity

"otal Ministry Miles. Reimbursement amount 0milea#e C .9< per mile1.

0 $0.00