Reimbursement Request Form printable pdf download

Transportation Expense Reimbursement Account

REIMBURSEMENT REQUEST FORM

Employer

________________________________________________________________________________________________

Employee Name ____________________________________________________ Soc.Sec.No. ___________________________

Last

First

M.I.

Home Address ____________________________________________________________________________________________

Number/Street

City

State

Zip

Daytime Telephone Number _______________________________ E-mail Address _____________________________________

Please check only if this is a new address

Please Note: Expenses must be broken down on a per month basis.

Date Service Was

(Example)

Provided (Cannot Span

1/1/15 –

More Than One Month)

1/30/15

Type of Expense

(Transit Pass,

Commuter Highway

Parking

Vehicle, or Qualified

Parking)

Proof of Expense

Yes

Attached? If not, explain

why proof not available.

Total Expense

$90

Total Amount

Requested

IMPORTANT: Please attach supporting documentation of your expense. A receipt from your parking or transit provider is preferable,

itemizing the months of service, description (parking) and date of payment. For transit pass reimbursement, a used time-sensitive transit

pass (such as a monthly pass) is preferable. If a receipt is not available from your provider, you may attach a copy of your cancelled check

verifying payment, or a copy of an unused transit pass may be used along with signing the certification below.

I certify that I used the Transportation Benefit for which I am requesting reimbursement above only for purposes of parking or commuting to

and from work at my Employer for the time period shown above. I also certify that I have received the services described above on the dates

indicated, and the expenses are my out-of-pocket expenses that qualify as valid Transportation Expenses under the Plan. I have not been

reimbursed previously for these expenses under the Plan, and these expenses have not been reimbursed or are not reimbursable under

any other plan or source. I understand that the expenses reimbursed may not be used to claim any federal income tax deduction or credit,

or to claim reimbursement under another plan.

Employee Signature

Date

Arcadia Benefits Group, Inc.

612 S. Park St.,  Kalamazoo, MI 49007



Phone: 269-744-3431

Toll Free Phone: 866-329-4333



Fax: 269-381-5844

Toll-Free Fax: 844-560-6753

E-mail:

Rev. 8/15

Reimbursement Request Form

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