NDASCOE

Reimbursement Expenditure Request

 

**Please Attach Receipts**

 

I, ____________________________________, hereby request reimbursement for the following listed items:

 

Itemized Breakdown:

 

Mileage_______________@________  $__________________

Purpose/Event: ______________________________________

 

 

Item                               Amount              Purpose/Event

(Stamps, paper, room ect.)                                         (Newsletter, scholarships, Rally, ect.)

 

_________________   $___________   ____________________

_________________   $___________   ____________________

_________________   $___________   ____________________

_________________   $___________   ____________________

_________________   $___________   ____________________

 

 

Total amount requested: $______________________________

 

Signature of Requester: ________________________________

 

 

Signature of Approval:_________________________________

 

Paid/date__________________  Check number_____________

By:_______________________          (Treasurer)