IHC Reimbursement Request
Please fill out this form to request reimbursement for IHC-related and/or Harm Reduction Team expenses.
Sign in to Google to save your progress. Learn more
Email *
Instructions - Please Read
We primarily conduct reimbursement requests through Zelle and Venmo. Follow the instructions below to indicate your preference. Should you need a different form of reimbursement request (Cash/Check/etc...) please email cristina@ihcucsd.org

FOR IHC MEMBERS:
1. Reimbursement requests over $25 not previously approved by the CFO/Treasurer and/or are missing receipts may not be granted if only this form is submitted. 
2. In addition to completing this form, please email relevant photos of receipts and/or screenshots to admin@ihcucsd.org with "Reimbursement Receipt - Your Name" in the subject line. 

FOR ALL OTHERS:
In addition to completing this form, please email relevant photos of receipts and/or screenshots to admin@ihcucsd.org with "Reimbursement Receipt - Your Name" in the subject line. 

Please contact the current CFO/Treasurer (cristina@ihcucsd.org) with reimbursement issues/questions.
Full Name *
First and Last Name
Date *
When did the expense occur?
MM
/
DD
/
YYYY
Requested Reimbursement Amount *
Details of Purchase *
Reason for purchase and relevant details. 

Include things like: location traveled to/from, insurance, supplies, etc. Please be specific. ex. "Drove Members to Mar Vista High from UCSD 3 times" or "Purchased art supplies for June 2019 ELC". 

If you are a member of the Harm Reduction Team, please type "Harm Reduction Reimbursement"
Zelle Contact *
1. If you prefer to use Zelle please provide your phone number OR email associated with your bank account
2. First time zelle users: https://www.zellepay.com/get-started
3. Type "N/A" if you prefer to use Venmo, move onto the following question
Venmo Username *
1. If you prefer to use venmo please provide your Venmo user name
2. Add @ihcihc as a friend on Venmo
3. Type "N/A" if you prefer to use Zelle
Is this a gasoline reimbursement request?
If you drove a car for an IHC related event, we will reimburse you for gas prices.
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of International Health Collective. Report Abuse
Google Forms