Employee Expenditure Reimbursement Request Form

Reimbursement Information

Page 1
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Primary Building Assignment:*
Code
Admin Asst E-mail*
This should autofill based on your building assignment listed above.
Is this Reimbursement Request for a Professional Leave that Required Prior Approval?*
Please Upload Your Prior Supervisor Approval for This Leave:

This would have been the PDF emailed to you from your original Professional Leave Request Form.
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Check each reimbursement category below that you will be submitting, along with dollar amounts*

Note - If submitting a Mileage Reimbursement Claim, you MUST attach a signed PDF copy of the Mileage Reimbursement Claim Form.
Total Reimbursement Submission:
Attachments - Travel Costs

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Attachments - Travel Costs (additional upload if necessary)

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Attachments - Mileage Reimbursement

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Attachments - Mileage Reimbursement (additional upload if necessary)

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Attachments - Meals

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Attachments - Meals (additional upload if necessary)

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Attachments - Other Incidental Expenses

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Attachments - Other Incidental Expenses (additional upload if necessary)

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Professional Leave Request - PO Details & Policy Acknowledgement

Page 3
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What is the Purchase Order number in Skyward for this request?
Please have your Administrative Assistant create a Purchase Order for you. The amount should match what you are claiming on this form.

Contact your immediate supervisor if you have any questions.
Account to Be Expensed - All Travel Costs*
If you do not know this account, please contact your immediate supervisor
Attestation Statement

I hereby affirm that the expenses detailed in my Professional Leave Expense Reimbursement Form are a true representation of eligible reimbursements intended exclusively for my personal use. I confirm that these expenses do not include the procurement of any prohibited items, including alcoholic beverages or any other ineligible goods.

Signing below indicates all expenditure estimates and trip information listed are accurate to my knoweldge and that I have reviewed all applicable MCCSC travel policies.
Signature

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Expenditure Reimbursement Request Form