Ortonville Independent School District #2903
Revised: 01.01.10
Expense Reimbursement Request Form
(See page 2 of this form for information on reimbursement policy and procedure)
Account Code
FD
ORG
PRO
CRS
FIN
OB J
Amount
Date:
Purpose & Place of Attendance and/or Item Purchased
Personal
Vehicle
Miles
Traveled
Meal
Expense
Check Meals
B L D
Other
Travel
Expenses
Non Travel
Expenses
Total Miles:
X's $.50
Column
Column
Column
(IRS Rate)
Total
Total
Total
Total Amount
Claimed
Authorization Signature
I declare under the penalties of law that this account, claim or
demand is just and correct and that no part of it has been paid.
Signature
Date
Name
Address
City, State, Zip
Ortonville Independent School District #2903
Expense Reimbursement Request Form
Unless specified otherwise in an applicable contract or agreement, the following limits apply to
reimbursement of expenses:
1. Mileage currently is $.50 cents per mile (IRS Rate) (Rate Effective 01/01/10)
** When more than one employee is making the same trip at the same time, employees are expected
to share transportation to minimize costs. **
2. Room allowances should be decided with Administrators prior to the event.
3. Parking fees will be reimbursed for full cost with a receipt.
4. If required to leave before 7:00 AM and/or return after 6:00 PM, meals will be reimbursed up to the
following limits with receipts:
Breakfast:
$ 8.00
Lunch:
$10.00
Dinner:
$17.00
The actual cost above the limits will be reimbursed if the cost is required as part of the meeting
package.
NOTE:
Requests turned in by the 10th of the month,
Will be paid at the regular business meeting
For the month.