REQUEST FOR REIMBURSEMENT
No Travel or Entertainment (food) expenses on this form.
Reimbursements under $25, use the Petty Cash form.
Reimbursements will be directly deposited into your bank account for those who
have elected direct deposit via payroll, or by check for all others.
Tax will not be reimbursed.
Attach all ORIGINAL, ITEMIZED receipts to back of form.
If your address has changed, fill out a W-9.
SS # (last 4 digits) U.S. citizen: yes no*
and Penn ID #
intramural: MB# and mailcode
*If not a U.S. citizen, attach a Foreign National Information Form and copies of
your Passport, Visa, I-94 and I-20.
List all expenses below. Be specific. The description must fully explain the expense;
e.g., ‘duplicating agendas for general meeting, refreshments for....’
Budget Categories are specific to your group’s funding. SAC groups: Check your
budget for the appropriate category; SPEC: committee or CRef; GISAC groups: Review
GAPSA guidelines; GAPSA: committee such as Student Programs, Social, etc.; Others:
Description of Purchase Budget Category Amount
Total $ __________
Requestor Organization* E-mail
*Org: if not SAC or GISAC, enter funding source and your group.
Treasurer’s Approval (if required) E-mail Date Submitted