Expense Reimbursement Form

Reimbursement Rates

Required field

Personal Information

Date

First Name

Last Name

Phone

Address Line 1

Address Line 2

City

State

ZIP Code

Who Check Is For

Affiliate / Committee

Driver / Guide (name, if applicable)

Event / Meeting

Event / Meeting Name

Start Date

End Date

Mileage & Transportation

Start Address

End Address

Miles Driven

Mileage Total ($0.70/mile)

Bus / Cab / Train Fare

Other Transportation

Explanation of Other Transportation

Total Transportation

Meals & Other Expenditures

Total Cost of Meals (max $60/day)

Other Expenditures

Explanation of Other Expenditures (submit receipts if possible)

Grand Total

Grand Total for Reimbursement

Signature

Full Name (Electronic Signature)

By typing your name, you certify that all information is accurate and complete.

Fill in the Word document on your computer and email it to aa@moblind.org.

Mail to:

Missouri Council of the Blind
5453 Chippewa Street
St. Louis, MO 63109