Expense Form/Request for Payment

"*" indicates required fields

This is for*

Receipt Date*

Last Two Digits of Card Number*

Today's Date*

Purchaser's Name OR Person to be Reimbursed*

First Last

Name of Person Submitting This*

First Last

Your Email*

We will use this to email you confirmation that your receipt has been submitted

Name of Childcare Worker*

First Last

This is the teen or individual that will be provided payment for providing childcare. This individual must be at least 13 years old. This form will need to be submitted separately for each individual that provided childcare.

List of Dates*

LIfeGroup or Event

Date

You can hit the plus sign on the right to add additional dates.

Signature of LifeGroup or Event Leader (must be 18 or older)*

* I CERTIFY THAT I AM THE PERSON MAKING THE PAYMENT REQUEST AND THAT THE INDIVIDUAL NAMED ABOVE DID PROVIDE CHILDCARE FOR MY LIFEGROUP OR EVENT

Make Check Payable To*

Please also add mailing address if it’s not on the bill.

What Are We Paying For?*

ie, face painting at Fall Festival

Amount Due*

Place of Purchase*

You will need to submit a separate form for each receipt. Exception: Gas mileage reporting.

Starting Location*

Destination*

Place, city and state. If you have multiple receipts for ONE destination purpose, you can upload with this one form.

Ministry Purpose*

ie, to transport missions team to airport for missions trip

What Did You Purchase? List only items belonging to the same expense line.*

Items purchased from a different expense line will be added below.

Take This From What Budget Expense Line?*

Total Amount for This Item*

This is the amount to post from this expense line.

Was This a Lodging or Restaurant Expense?*

By restaurant expense we don’t mean something like fast food items purchased for youth group meetings, but rather something like taking someone out to eat at a restaurant for a specific ministry purpose.

How Many Nights Did You Spend?*

Name and Address of Lodging Place or Restaurant*

Include address if it is not on the receipt.

Who Attended?*

This is where you will list everyone who was present (ie, stayed at the lodging place or ate at the restaurant). Separate names with commas.

Purpose*

This is where you list the purpose for the lodging or restaurant expense (ie, lodging for youth beach trip; lunch to discuss new bank loan). It is the WHY.

Do You Have More Items From This Receipt (for different expense line)?*

What Did You Purchase? List only items belonging to the same expense line.*

Items purchased from a different expense line will be added below.

Take This From What Budget Expense Line?*

Total Amount for This Item*

This is the amount to post from this expense line.

Do You Have More Items From This Receipt (for different expense line)?*

What Did You Purchase? List only items belonging to the same expense line.*

Items purchased from a different expense line will be added below.

Take This From What Budget Expense Line?*

Total Amount for This Item*

This is the amount to post from this expense line.

Starting Odometer*

Ending Odometer*

Total Miles of Trip*

Parking Fees/Tolls Amount

Total Amount*

Total of gas, parking fees, and tolls

Comments

Total Amount Charged on This Receipt*

Upload Your Receipt or Bill Here*

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

All purchases/reimbursements require a receipt. However, if you are unable to obtain a copy of a lost receipt, please fill out a paper expense report form. This should be the exception, not the norm.

Upload Gas Receipt(s) Here*

Drop files here or

Accepted file types: pdf, png, jpg, Max. file size: 64 MB.

If you have multiple receipts for ONE destination purpose, you can upload with this one form. Mileage reimbursement for out of pocket expenses will be 34 cents per mile, and/or tolls/parking fees.

Phone

This field is for validation purposes and should be left unchanged.