Reimbursement Request Form
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1Reimbursement Request
Original Itemized Receipts Required
REIMBURSEMENT WILL NOT BE SUBMITTED WITHOUT A MEMO OF
EXPLANATION STATING THE REASON FOR THE PURCHASE
AND WHY IT WAS NOT DONE THROUGH THE DEPARTMENT
Date: _________________
Payee Name:
U of Utah ID:
________________________________________
___________________________
Email:
Phone:
__________________________________________
_________________________________
Faculty Advisor (please print)
____________________________________________________________
Class/Team Name & Number: _________________________________________________________
Chartfield: 01 - 00068 - ________ (
) - _________________ (
)
Fund
Activity or project
The
P AYEE
S IGNATURE
i s
r equired
f or
a ll
e mployee/student
r eimbursements,
a nd
m ust
i nclude
a
r eadable
p rint
o f
their
n ame,
u NID/EmplID,
a nd
e mail
a ddress.
I certify t
hat these expenses were actual, necessary, reasonable and incurred for official business of the University
of Utah and that no portion of this claim was provided free of charge, previously reimbursed from any other source, or
will be paid from any other sources in the future.
PAYEE SIGNATURE_____________________________________ DATE_______________________
Authorized by Faculty Advisor:_________________________________________________________
(Faculty signature required)
Non – U of U students and staff will need to complete a W-9 for reimbursement.
Please Check One:
- I will pick up the Check.
- Mail the check to the address below.
Name: _______________________________________________________________________________
Address: ____________________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Phone: 1 – (
)
-
EXT -
Fax: 1 – (
)
-
M i s s i n g o r i n c o m p l e t e f o r m s c a n c a u s e a d e l a y i n p r o c e s s i n g .
P l e a s e i n c l u d e y o u r p r o o f o f p a y m e n t ( C a s h R e c e i p t s , C r e d i t C a r d
S t a t e m e n t s … ) .
Meal Reimbursement Requirements:
Description of meal purpose: ___________________________________________________________________
•
Number of attendees: _________ (If less than 11 attendees; list the names of all attendees on the back)
•
An Itemized receipt of the food purchased is required.
•
Sales Tax Will Not Be Reimbursed
Vendor Name - (
)
Receipt Total w/o Tax
Each receipt
Total
Revised April 2011
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Parent category: Business