Internal Receipt Reimbursement Form

Name of payor(Required)

First Last

Name of submitter (if different)

First Last

Date of purchase(Required)

Program Expense(Required)

Water Quality

Invasive Aquatic Species

Annual Conference

Climate Change Resilience

Admin

Development

Other

If a cost should be split amongst programs, please select Other and indicate the split percentage

Account(Required)

Please select the appropriate expense account

Task

Vendor or "Gas"

Detail of purchases / Leg of trip

If submitting for gas reimbursement, please include the distance travelled in miles as well as destination location. Id est Auburn to Sebago Lake and back - 68 miles.

Total amount(Required)

Total amount or total = miles driven x $0.67 / mile

Hidden

Documentation of receipt

Max. file size: 8 MB.

Documentation of receipt(s)

Drop files here or

Max. file size: 8 MB.