VV A Chapter 391 
Travel Reimbursement Form 
Name: 
Position/Committee 
or Budget(s) to Cbarge 
Address (circle Home or Chapter): 
City: 
----------------------- 
State/Zip: 
Phone; 
Purpose of TravelfExpense (Include dates); 
Expenses: Note: Chapter has a 45 day reimbursement policy -If this claim is IJOt submitted timely to the 
Treasurer it will be treated as a non-budgeted expense item. Thus YOIl will be require to submlt to the 
finance committee and gel approval before any reimbursement will be made. 
1. Travel:
Plane, Train, etc. (coach or economy rates only) 
Car@ $ 0.50	Per Mile x 	. 	# of miles) 	_$	_ 
$ 
Tolls 
------ 
Car Rental 
------ 
Etc. 
------ 
Bus 
Other- 
Taxi 
$ 
Gas 
(Show cost comparison to mileage amount, when other transportation claimed) 
Total= $ 
------ 
2. Pel' DiemlLodging : 
A. Meals @ 50.00 per day 
( Attach Original Receipts) 
	X 	days 
--- 
Total = $ 
..:-~---- 
B. Lodging (Not to exceed $120.00 daily excluding taxes) 
C.	Less restricted items 
Explanation: 
(ie Ill-room movies, Room Service) 
(must enter negative value) 
-------- 
(B-C=) Sub:Total: $
------ 
(A+B-C=) Total= $ 
------ ... 
3. Other Reimbursement Items: A. 
------------------------ 
	( Attach Original Receipts)	 B. 
----------------------- 
c. 
------------------------- 
D. 
Total= $
------ 
4. Grand Total: 
$
5. Signature:	Date: 
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NOTE:Non-Budgeted Items - must receive approval hy Finance Committee: (Two Signatures) 
Mail to: 
George Hunter 
8400 Old Melones Dam Rd. #86 
Jamestown, CA 95327 
When Required: 
Finance Committee Approval: (Two Signatures) 
1.) 
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ACCOUNTING USE ONLY 
Date Paid: 
---------------- 
Chcck#: 
Amount: 
2.) 
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Revised 12/2018 
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