Clear All entries
Rev 001
COAST GUARD AUXILIARY ASSOCIATION, INC.
CGAuxA-4 (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: ________________
Claimant paid
EXPENSE TYPE:
out-of-pocket
1. FAX .............................................................................................. $ ___________
2. Telephone .................................................................................... $ ___________
3. Email ............................................................................................ $ ___________
4. Supplies / Printing ........................................................................ $ ___________
5. Other ______________________________________________ $ ___________
6. Other ______________________________________________ $ ___________
7. Other ______________________________________________ $ ___________
8. Other ______________________________________________ $ ___________
9. Total: ............................................................................................ $ ___________
10. Reimbursement due claimant: ...................................................... $ ___________
COMMENTS
AUXCEN USE ONLY
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
instructions on page 2 of this form.
____________________________________
_________________
Member signature
Date
____________________________________
_________________
NON-TRAVEL EXPENSE APPROVED
approved Department Chief
Date
____________________________________
_________________
approved NADCO
Date
____________________________________
____________________________________
_________________
Authorized signature
approved (NACO/NAVCO)
Date
7E7.08F
1
2
