Clear All entries
Rev 001
COAST GUARD AUXILIARY ASSOCIATION, INC.
CGAuxA-4A (1-08)
CLAIM FOR REIMBURSEMENT - NON-TRAVEL FORM
NAME _________________________________________ AUXILIARY OFFICE ____________________
ADDRESS _________________________________________ BUDGET ACCOUNT ___________________
CITY _________________________________________ ST ____ ZIP __________________________
EMAIL _________________________________________ PHONE ______________________________
Check here
if NOT a grant associated expense. If expense WAS incurred in conjunction with a grant, enter:
Grant Name: __________________________________________
Grant Number: _________________
Category
CGAuxA
Claimant paid
EXPENSE TYPE:
total:
credit card
out-of-pocket
1. FAX ...................................................................$ ___________ $ ___________ $ __________
2. Telephone .........................................................$ ___________ $ ___________ $ __________
3. Email .................................................................$ ___________ $ ___________ $ __________
4. Supplies / Printing .............................................$ ___________ $ ___________ $ __________
5. Other ________________________________ $ ___________ $ ___________ $ __________
6. Other ________________________________ $ ___________ $ ___________ $ __________
7. Other ________________________________ $ ___________ $ ___________ $ __________
8. Other ________________________________ $ ___________ $ ___________ $ __________
9. Totals .................................................................$ ___________ $ ___________ $ __________
10. Adjustments .............................................................................................................. $ __________
11. Reimbursement due claimant: .................................................................................. $ __________
AUXCEN USE ONLY
COMMENTS
SIGNATURE OF CLAIMANT
This statement and all items attached are true. I am
aware that this claim for reimbursement must be
completed and forwarded within seven (7) days after
the expense was incurred in accordance with the in-
structions on page 2 of this form.
____________________________________
_________________
Member signature
Date
____________________________________
_________________
NON-TRAVEL EXPENSE APPROVED
approved Department Chief
Date
____________________________________
_________________
approved NADCO
Date
____________________________________
_________________
____________________________________
_________________
Authorized Signature
Date
approved (NACO/NAVCO)
Date
8.1E8.102F
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