You may browse through our Reimbursement Request Forms below for samples that are easy to download. Use this Request for Reimbursement form to ask for payment from your HRA for eligible care you’ve already paid for with a credit card, cash or check. ① Account Holder Information: The Account Holder is usually the retiree or the surviving spouse. Applicant Information [All fields mandatory unless otherwise noted] OMB 3060-1271. If an expense is … Anyone can request for the reimbursement of money which he or she has spent on any activity or process taking place in business. A reimbursement request form is a document which is used by organizations to collect data and information from their members who will want to acquire a reimbursed payment in lieu of any service or financial transaction which had been conducted. Detailed receipts should be submitted along with the form. Identify each expense as M (Medical), D (Dental), V (Vision), H (Hearing), or O (Other), under Type of Expense. REQUEST FOR REIMBURSEMENT OF DRIVER’S LICENSE REINSTATEMENT FEE I, _____, submit request for reimbursement of the reinstatement of my Class D Driver’s License, and attests as follows: ... attach copy of Reinstatement Order Form or Purchase Receipt, etc.) More templates like this. Mailing … • Reimbursement requests can take up to 30 days to be processed. You can use these samples as a basis for your own forms so that you won’t have to make your own forms from scratch. The requestor will have to state the type of reimbursement that he is requesting along with with his employee data and information, the details of the mobile device, the approved usage level, his justification, and the calculation of the expenses. FAQ and Reimbursement Request Form For faculty or non-union staff members What is the RP? Directions for Requesting Reimbursement. Reimbursement claim letter is an official letter to request the refund of authorized expenses. Recurring premium requests must be resubmitted each calendar year. Parent is not enrolled in the same Group Health plan as the child 2. This is important to practice transparency in the workplace and to promote honesty. This reimbursement form was designed to allow employees to request reimbursement for general business expenses. ATTACH ALL RECEIPTS TO THIS EXPENSE STATEMENT . You can also check out our Sample Tuition Reimbursement Forms for use by students who wish to request for tuition reimbursements. It covers all the relevant information regarding the expenses and the demand of reimbursement. Regardless of the type of reimbursement request form that organizations will use, the form should have the following sections and contents for it to be an efficient document the financial aid department or provider can use for their reimbursement procedures: The details of the claimant or the person who is requesting the reimbursement will have to be documented in the form including his identification numbers, address, and contact information. Harvard University provides a unique reimbursement program to assist employees who face high medical costs during the plan year. If a copy is submitted instead of an original, an explanation as to why a copy is being submitted should also be stated. This accessible template is intended for a school and educational settings. It is also important that each Reimbursement Request Form is substantiated by providing proof for the expenses, such as receipts. You do not have to enroll in this coverage, but you do need to meet the eligibility requirements. There are times when employees travel to attend meetings and conferences, or even host them. Reimbursement Request Forms are used by organizations to formally document requests for reimbursement so that these can be processed and funds can be expended promptly. Name of Payee PTA Position Address City/Zip Telephone ( ) Email . What expenses are eligible? The purpose of a certification statement is to indicate that the claimant or the requestor affirms the data and information that he had disclosed and stated in the request form.