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MBCLEO Expense Form
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MBCLEO Expense Form
MBCLEO Expense Form
Dene Westbrook
2025-06-04T10:07:48-04:00
MI Black Caucus – Local Elected Officials Expense Reimbursement
Date
*
Name
*
Name
First Name
First Name
Last Name
Last Name
Email
*
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Municipality/Organization
*
Reimbursement Payable To:
*
Individual
Organization
Travel Start Date
*
Purpose of Reimbursement
*
NLC Travel – Cap $500
Airfare
Airfare
$
Luggage
$
Total Airfare & Luggage
Mileage
Date
Mileage
Add
Remove
Total Miles
2025 IRS Mileage Rate
Total Mileage Reimbursement
Meals
Date
Meal Type
Breakfast
Lunch
Dinner
Amount
$
Add
Remove
Total Meals
Miscellaneous Travel Fees (parking, taxi, hotel, etc.)
Description
Amount
$
Add
Remove
Total Misc Fees
Total
Total Expenses
Total Reimbursement (If total expense exceeds CAP of $500, $500 will auto populate)
Acknowledgement
Signature – I certify that the above expenses were incurred while providing a service to the Michigan Black Caucus – Local Elected Officials and have provided any applicable receipts as support to my reimbursement.
*
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keyboard
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File Upload – All expenses over $20 requires supporting receipts.
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Maximum file size: 20.48MB
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