Complete the form now or create a blank template? Complete the form now or create a blank template? Complete the form nowCreate a blank template Name of the employee seeking reimbursement Day that the travel began Day that the travel ended If the same day, make the end date be the same day. What was the purpose of the trip? How many miles driven? Miles Round to the nearest mile. Enter the rate per mile $/ mile 2026 Rates (an employer may pay a different rate)Business: $0.725Medical: $0.205Charitable Service: $0.14Source: IRS Total Reimbursement (Automatically Computed) Are there any other expenses you are requesting reimbursement for? Are there any other expenses you are requesting reimbursement for? YesNo Such as tolls, parking fees, food, lodging, or other expenses. Select Items Select Items TollsParking FeesFoodLodgingOther Tolls $ Parking Fees $ Food Costs $ Lodging Costs $ Enter any other Items you wish to be reimbursed for: Employer that will reimburse the employee Do you have receipts for any of these reimbursed items? Do you have receipts for any of these reimbursed items? YesNo Would you like to sign this request electronically? Would you like to sign this request electronically? YesNo Sign and Print Clear Please draw your signature. Print Name Date of this request Usually today’s date Next Save Save and finish later
