Social Club Reimbursement Form (Page 2 of 4) in pdf

Social Club Reimbursement Form Page 2

UNIVERSITY OF NORTH TEXAS SYSTEM

SOCIAL ORGANIZATION MEMBERSHIP REIMBURSEMENT FORM

Employee Name:

Club:

Reimbursement Period (Month/Year):

Business Expenses

Dues

Annual Charges

Please complete the Business Expense Log below for each business expenditure at or near the time of each expense. Attach receipts for each

business expense. Also attach the monthly club statement, with each charge marked as “B” for business, “P” for personal (including any food

minimum charges), “D” for dues (including automatic monthly charges other than food minimum charges), or “A” for annual charge.

Enter the number of days (if any) that the club was used by you or your family during this monthly period without having incurred any charges

(examples include personal use the club facilities where no fee is incurred such as the swimming pool): ___________

I hereby certify that the information contained on this form, including the information listed in the Business Expense Log below, is true and

correct and relates to expenditures actually incurred.

Employee’s Signature:

_____

Date:

Supervisor’s Signature:

________________________________________

Date: ___________________________________

Should equal the sum of all expenses listed in the Business Expense Log below.

Include automatic monthly charges other than food minimum charges, such as monthly locker fees and range fees.

Social Club Reimbursement Form Page 2