Regional Expense Reimbursement Request Form

Date*
Date Format: YYYY slash MM slash DD

Enter the date you are submitting the form
Enter your first and last name*
First Last
Your Email*

Enter your email address
Pay to you or to outside Vendor?*
- Pay me (reimbursement)
- Pay an outside Vendor
Name of Outside Vendor or Entity to pay*
Outside Vendor's name should appear on the invoice/receipt you're uploading.
Reimbursement Type Requested*
- Standard check by Mail (7-10 business days)
- Zelle
- PayPal
How do you want to be reimbursed?
Enter mailing address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email or Phone # for Zelle Payment
Enter the email or phone # associated with your Zelle
Email or Phone # for PayPal Payment
Enter the email or phone # associated with your PayPal account
List all expenses incurred that need to be reimbursed*
Description of Expense Amount of Expense
Receipt upload*
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Upload a copy of your receipt(s)
*FINANCE COORDINATOR USE ONLY* Payment Status
- Paid
*FINANCE COORDINATOR USE ONLY* Payment Date
Date Format: YYYY slash MM slash DD
*FINANCE COORDINATOR USE ONLY* Check # or Transaction #
Name
This field is for validation purposes and should be left unchanged.

Description of Expense	Amount of Expense