CELLULAR TELEPHONE REIMBURSEMENT FORM
Name: _____________________________________ Date:____________________
Social Security: ______________________________ Position: ________________
The Reimbursement Form must include the required information and a copy of the employee’s cellular
telephone bill must be attached to the form. For confidentiality reasons, employees should only attach a copy
of the portion of their bill which is returned to the carrier with the payment. It is not necessary for the
employee to submit itemized call details with their Reimbursement Form.
Reimbursement Forms should be submitted to the Business Manager by the 1 of each month for
reimbursement of the previous month. A check for the reimbursement amount of Twenty Five Dollars ($25)
will be distributed to the appropriate employees by the 10 of each month.
For more information, see Policy and Procedures Manual, Policy #9060.
Indicate Month and Year of Reimbursement: 2004 2005 2006
January February March April
May June July August
September October November December
A copy of your phone bill must be attached to this form.
By signing below, I request reimbursement for the use of my personal cellular telephone, which I used in
accordance with Lighted Pathways Health Services, Inc. Policy and Procedures Manual, Policy #9060.
Employee’s Signature: _____________________________ Date ________________
Supervisor’s Signature: _____________________________ Date ________________
Lighted Pathways Health Services, Inc. July, 2003