Expense Reimbursement Form

Print completed form and send along with receipts to:
Democracy Matters / 201 Riverview Drive, Poughkeepsie, NY 12601

Campus Coordinator Information
	Today’s Date (ex: 11/11/15)
	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

Name