8/13/2019 Reimbursement Form '13

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Reimbursement FormName: Complete all information. Incomplete forms will result in delays.

Address:

City:

State: Zip: Period Covered:

1. Transportation, Parking, Tolls1. $0 Air, bus, taxi, driver, etc. Ministry related only, !" daily commutin# costs.

2. Meetings and Retreats2. $0

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

. Corresponden!e. $0

"elpone ministry calls, prayer letters, posta#e, printin#, etc.

". Meals and Per #iem". $0

%&'I('' )&R)!'( !*+. For current per diem rate, see rate cart.

$. %odging$. $0

ot for movin#. Receipt reuired.

&. C'ild!are&. $0

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

(. S)pplies and Materials (. $0.00!nly items for ministry wor- may be reimbursed. *ist on bac-.

*. Mis!ellaneo)s*. $0.00

(xplain

+. S)m o lines ( and * +. $0

1-. Reim)rsale Claims1-.

 As indicated on insurance co. wor-seet.

11. Ann)al p'ysi!al, dental, vision, 'earing !are and ot'er.11.

 Attac Receipts.

12. S)m o lines 1- and 11 12. $01. Nonta/ale Co)nseling 1.

1". $0

1$. $01&. A)to P)r!'ase Sales Agreement is:

1(. $0

1*. $0

'alary

1+. $0

2-.

21. 0a!k Pay 21.

Movin# 22. Moving: Minim)m $ miles.22.

(xpenses Include receipts and itemi/e transporation, lod#in#, meals, auto milea#e, #asoline, etc1

Advance 2.

"otal

2". S)m o lines 12 2". $02$. Amo)nt o reim)rsement advan!e to e !leared. 2$.

2&. rand Total 3line 2$ s)tra!ted rom line 2"4 2&. $0

Spe!ial 5nstr)!tions: Take Ta/ale: 0.00

oteTake NonTa/ale: $0.00

Advan!e: $0.00

'taff Member 'i#nature2222222222222222222222222222222222222222222 3ate222222222222

Approval 'i#nature22222222222222222222222222222222222222222222222 3ate222222222222

!ri#inal itemi/ed bills or receipts must be attaced for 41 all airline fares, 51lod#in#, 61 all medical expenses, and 71 all sin#le expenditures of $89 ormore. 3! !" (C*!'( R(C(I)"' &*('' R(:&IR(3.

Ministry(xpensesComplete'cedule

Medical(xpenses

 AutoComplete'cedule

1". Ministry A)tomoile 6/pense From 'cedule C;91

1$. Personal A)tomoile 6/pense From 'cedule C;<1

1(. Ministry A)to P)r!'ase From 'cedule 3;51

1*. Personal A)tomoile 6/pense From 'cedule 3;61

1+. Additional Salary (nter total bein# claimed1

2-. Ta/ Allo7an!e 'um of lines 49, 4=, 4>; multiplied by te appropriate rate1

2. Reim. Advan!e )urpose

 'pecial instructions below

Clearin# an advance

Reuestin# an advance

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Itemi/ation of all claimed expensesCategory 3line no.4: #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

1. Transportation, Parkingand Tolls

8/13/2019 Reimbursement Form '13

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Itemi/ation of all claimed expensesCategory 3line no.4: #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

1. Transportation, Parkingand Tolls

8/13/2019 Reimbursement Form '13

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Itemi/ation of all claimed expensesCategory 3line no.4: #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

1. Transportation, Parkingand Tolls

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 Automobile (xpenses and (xtra 'alary

 Automobile Maintenance and !peration

C;4 Calculate Milea#e and )ercenta#es

(nter ministry milea#e )ercenta#e Ministry Miles 0.00?

(nter )ersonal milea#e )ercenta#e )ersonal Miles 0.00?

"otal 0 "otal 0.00?

*ist wee-ly totals below

C;5 @as, !il, *ube, as C;6 Repairs, )arts, Insurance, Re#, etc.

3ate Amount 3ate Amount 3ate Amount Item

C;5 "otal $0.00 C;6 "otal $0.00

C;7 "otal Auto (xpenses1 $0.00

C;9 Ministry Auto (xpenses1 $0.00C;< )ersonal Auto (xpenses1 $0.00

 Automobile )urcase

'ales a#reement must be on file in accountin#1

3;4 "otal Amt. %ein# Claimed1 $0.00

3;5 Ministry )urcase Amt1 $0.00 3;5 B 3;4 C;4 Ministry ? Inserted on line 481

3;6 )ersonal )urcase Amt1 $0.00 3;6 B 3;4 C;4 )ersonal ? Inserted on line 4=1

 Additional 'alary

Includes settlin# in, plannin# wee-ends, expenses for cildred. *ist dates and expenses below. "otal inserted on line 4>

3ate Amount Item, 3escription, )urpose

(nter te total amount you are claimin# on tisreimbursement.

)lannin# ee-end 'ettlin# In 'pecial eeds 'alary !ter; (xplain %elow

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Automobile (xpenses; )er Mile

C$ A)tomoile Mileage Reim)rsement

3ate Milea#e Ministry activity

"otal Ministry Miles 0

Reimbursement amount milea#e .9< per mile1 $0.00