Expense Reimbursement Form

Print completed form and send along with receipts to:
Democracy Matters / P.O. Box 157 / Hamilton, NY 13346

Campus Coordinator Information

 


Today's Date (ex: 11/11/02)

 


Your Name

 


College / University

 


Name of Campus Coordinator
(all reimbursement checks will made out to Campus Coordinator)

Where should we send your reimbursement check?

 


Building / Suite/ Apt# / Floor / etc.

 


Street

 


City


State


Zip

 


Expense Description (Please state clearly the purpose of the expense)

 

Date of Expense

Purpose of Expense

Amount

 

 

 

 

 

 

 

 

TOTAL AMOUNT

 

 

X___________________________________Campus Coordinator Signature

 

 
   
 

 

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The Democracy Matters Institute / PO Box 157 / Hamilton, NY 13346