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Reimbursement
Use this form to submit receipts for reimbursement by the TIPYC. The reimbursement will be reviewed by the accounting team.
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REQUESTOR INFORMATION
Full Name
*
First
Last
How would you like to receive the reimbursement check?
*
Direct Deposit
Mail to Address
Hold for Pickup
If you have Direct Deposit set up, you may choose that option for faster payment. Otherwise, we will mail your check to the address provided or hold for pick up.
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Email Address
*
Phone Number
*
Mailing Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
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
Zip Code
REIMBURSEMENT DETAILS
Provide as much detail as possible so we can process your reimbursement without delays. If you want your check mailed, please make sure you provide the correct mailing address.
Purpose of Expense
*
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Item/Service
Description
Actual Cost
1
1
1
2
2
2
3
3
3
4
4
4
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Upload Receipts
*
Click or drag files to this area to upload.
You can upload up to 10 files.
You must upload receipts for every expense claimed. For security reasons, some file types are not allowed
Total Expenses
$0.00
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Requestor's Signature
*
Clear Signature
Date of Request
*
Comments
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