Employee Reimbursement Form
Payment Method Purpose of Expenditure(s): Please give
Expense(s) (Out of Pocket or by detailed reasons for all expenditures.
Summary of Expenses
Expense Report Total
Air/Rail Ground Lodging Meals Other Total
I certify these are valid business expenses.
Reimburse/Cardholder Signature: ______________________
Reimburse/Cardholder Name: _________________________
Prepared by (Print): __________________
I have reviewed these expenses and I believe they are true and
Approved by (Print): __________________