Date:_________________________        Amount:_____________________________________

Name of Committee/Division/Roundtable/Other Unit:

_______________________________________________________________________________

Purpose and description of charge. (Attach receipts.) If travel is by car, the allowance is 40  cents per mile.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Make check payable to:

___________________________________________________________

Address to mail to:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________
Signature of authorized officer

______________________________________     _____________________________________
Phone number and TLA Unit

All reimbursement requests must be submitted by June 30 of the current fiscal year.