Student Reimbursement Form - Gerald R. Ford School Of Public Policy printable pdf download

Student Reimbursement Form - Gerald R. Ford School Of Public Policy

Student Reimbursement Form

Student Name: ____________________________________________ ID # _________________________

Course Number: _______ Term & Year: __________ Instructor: ________________________________

If reimbursement is not related to a course, please explain the purpose of the activity for which you are

seeking reimbursement: __________________________________________________________________

________________________________________________________________________________________

Items requesting reimbursement for:

Airfare

$ ____________

Lodging

$ ____________

Ground transportation

$ ____________

Mileage (attach mileage log)

_____ miles x $0.555/mile = $ ____________

Parking, toll costs

$ ____________

Copy/printing

$ ____________

Misc. Expenses

$ ____________

Total Submitted for Reimbursement:

$ ____________

PLEASE STAPLE MILEAGE LOG AND ORIGINAL RECEIPTS TO THIS REQUEST FORM.

ALL RECEIPTS MUST BE TAPED TO 8.5 X 11” PAPER.

Course related reimbursements: Students submit this form and attachments to their instructor for

approval, who will forward the paperwork on to Student Services personnel for processing.

Non-course related reimbursements: Students submit this form and attachments to the faculty or staff

member who has authorized the reimbursement, who will forward the paperwork on to Student

Services personnel for processing.

APS students: Please use the “Applied Policy Seminar (APS) Student Reimbursement Form.”

All requests for reimbursement must be submitted within 30 days of the incurred cost.

Student Signature: _____________________________________ _____________________________

Signature & Date

Print Name

Faculty/Staff Approval: _________________________________ _____________________________

Signature & Date

Print Name

FOR OFFICE USE ONLY

Date entered into system: ______________ Staff member initials: ______________________

Revised December 2012

Student Reimbursement Form - Gerald R. Ford School Of Public Policy