EXPENSE REIMBURSEMENT FORM

EXPENSE REIMBURSEMENT FORM

If you are due reimbursement from Team UT, please complete the form below and
drag and drop your receipts into the designated section.

If you have any questions or trouble with this form, please contact
Rainey Johns at rjohns2@utk.edu or 859.983.2223.
Name*

First NameLast Name
What is your role?*

GSMP MentorGSMP Program PartnerTeam UTOther
What is your organization?
Phone Number*
E-mail*
Address (where we should send your check)

Street Address

Street Address Line 2

CityState

Zip Code
Expense Detail

Expenses List (all reimbursements are subject to GSA rate requirements)

	Date of Expense	Vendor	Type of Expense	GL Budget Line (Team UT Only)	Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Total of Expenses (populates automatically)
Please attach a receipt for each expense listed above. *

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Mileage Reimbursement

	Date (M/D/Y)	Purpose of Trip	Starting Address	Destination Address	Total Miles This Trip
Trip 1
Trip 2
Trip 3
Trip 4

Total Miles Traveled (populates automatically)
Total Mileage Reimbursement (0.70/mile - populates automatically)
Please attach a map/maps with all stops.

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Total Reimbursement
Total Reimbursement (Expenses total + Mileage Total - (populates automatically)
I certify*

I certify that all information entered above is valid and true.
Should be Empty: