Who is the employee seeking reimbursement? Individual's Name Who is the company or employer that is reimbursing the individual? This is the company or employer that will be making the payment. When did the trip occur? Start Date End Date If the same day, make the end date be the same day. What was the purpose of the trip? Calculate the Mileage Reimbursement How many miles driven? Miles Round to the nearest mile. Enter the rate per mile (use current rates below) $/ mile 2026 RatesBusiness: $0.725Medical: $0.205Charitable Service: $0.14Source: www.irs.gov/tax-professionals/standard-mileage-rates MILES DRIVEN x RATE PER MILE $ CalculateExample - 100 miles driven X $0.725 = $72.50 Other Items Are there any OTHER EXPENSES requesting reimbursement? Are there any OTHER EXPENSES requesting reimbursement? YesNo Such as tolls, parking fees, food, lodging, or other expenses. Select Items Select Items TollsParking FeesFoodLodgingOther Tolls $ Parking Fees $ Food $ Lodging $ Enter any Other Items you wish to be reimbursed for: 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 Electronically Sign this request? Would you like to Electronically Sign this request? YesNo Sign and Print Clear Please draw your signature. Print Name Request Date Date of this Request Usually today’s date Next Save Save and finish later
