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MWIMG Expense Reimbursement Form
Michigan Municipal Women in Goverment Expense Reimbursement
Date
*
Name
*
Name
First
First
Last
Last
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
*
Mileage
Total Miles Driven
2023 IRS Mileage Rate
$
Total Mileage Expense
Meals
Date
Meal Type
Breakfast
Lunch
Dinner
Amount
$
Add
Remove
Total Meals
Airfare
Airfare
$
Luggage
$
Total Airfare & Luggage
Miscellaneous Travel Fees (parking, taxi, hotel, etc.)
Description
Amount
$
Add
Remove
Total Misc Fees
Total
Total Reimbursement
Acknowledgement
Signature – I certify that the above expenses were incurred while providing a service to the Michigan Municipal Women in Government and have provided any applicable receipts as support to my reimbursement.
*
Clear
File Upload – All expenses over $20 requires supporting receipts.
Drop a file here or click to upload
Choose File
Maximum upload size: 20.48MB
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