Reimbursement/Payment Request Form

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ATTENTION!!! PLEASE READ!! Please allow 2 weeks for processing. You may request payment to be sent directly to another entity or for personal reimbursement for any mileage or expenses.

**PLEASE USE THIS NEW FORM and Submit Receipts to ap@cmamad.org

Email *

Today's Date *

YYYY

Your Name *

Your Email *

Your Phone Number *

Your Address *

Please write: Total Mileage Amount which is: Total Miles x $0.655 *

Please write: Any Additional Expenses Total: *

Please Write: Total Mileage + Total Additional Expenses *

Please specify details of event and/or purpose. (What meeting, which event, who approved etc.) *

Choose whether you would like an electronic payment from our bank or a paper check mailed to the address you provided *

Electronic Payment

Paper Check

Before payment can be processed you MUST submit a photo of your additional expenses receipt to ap@cmamad.org *

I understand

By printing my name below I declare, under penalty of perjury, that this expense accounting is accurate and conforms with all Mid-Atlantic District and state and federal regulations. The expenses are actual, reasonable and were personally incurred in the performance of my duties for the Mid-Atlantic District. No portion of this claim was provided free of charge, was covered by a registration fee, was previously reimbursed from any other source, or will be paid from any other source in the future. *

A copy of your responses will be emailed to the address you provided.

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