DA Mileage Reimbursement Request Form

The IFO will pay delegate drivers 30 cents per mile plus 10 cents for each additional delegate passenger. In addition, the Board authorizes reimbursement of reasonable, documented child care expenses incurred by an authorized delegate in order to attend the Delegate Assembly.

Name

First Name

Last Name

Campus

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

i.e., 6125551212, no spaces or punctuation

(###)

###

####

Number of miles round-trip from your home address to the Radisson, 2540 N Cleveland Ave, Roseville MN 55112

Subtotal-Self

Multiply your round-trip mileage by $0.30 and enter the subtotal here.

Name of Passenger #1

Subtotal-P1

Multiply your round-trip mileage by $0.10 and enter the subtotal here.

Name of Passenger #2

Subtotal-P2

Multiply your round-trip mileage by $0.10 and enter the subtotal here.

Name of Passenger #3

Subtotal-P3

Multiply your round-trip mileage by $0.10 and enter the subtotal here.

Total Mileage Expense

Add subtotals for yourself and any passengers and enter the total here.

Childcare Expense

Enter total expense here. Email a receipt to blake@ifo.org showing hours, rate, and child(ren) cared for.

Total Reimbursement Requested

Add total mileage expense and total childcare expense and enter the grand total here.

I hereby certify that this is a true and correct statement of expenses that I incurred to attend IFO Delegate Assembly.

Check this box to affirm.

DA Mileage Reimbursement Request Form

Inter Faculty Organization

441 University Ave, St. Paul, MN 55103