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Instructions on completing the
REIMBURSEMENT
request form
This form should be used to request reimbursement for miscellaneous supplies and general expenses. Do not use this form for Travel or Entertainment expenses, to request payment for services, or to place an order for an item; the BSO has specific forms for these types of costs. It is always good practice to contact your budget assistant to determine whether a cost is reimbursable prior to purchasing anything (for a list of BSO Budget Assistants, click here). The university has restrictions against certain types of purchases, which may not be reimbursable.
All reimbursements must be accompanied by a receipt. Tape (do not staple) your receipt to a white sheet of 8½" x 11" paper (the back of scratch paper is fine).
Request Date: Enter today’s date.
Requestor Name: Enter the name of the individual requesting the ordered item(s).
Requestor Phone: Enter the phone number of the individual requesting the ordered item(s).
Requestor E-mail: Enter the e-mail address of the individual requesting the ordered item(s).
Payee (if not Requestor): Provide the name of the individual who should receive reimbursement, if it is not the same person completing the form.
Payment Address: This is the address where check will be mailed (students and employees: your check will either be mailed to your address on file or deposited via EFT).
Empl ID/Student ID/SS#/Fed Tax ID: Enter as appropriate the Employee ID, Student ID, Social Security, or Federal Tax ID of the individual or business to be paid. If a UCB employee is being reimbursed, provide his/her Employee ID; if a business is to be paid, provide its Federal Tax ID, etc.
Type of Expense to be Reimbursed: Select the type of purchase requiring reimbursement. If none of the available expense types are appropriate, select "Other" and describe the purchase. Note, however, that if you have not confirmed with your budget assistant that this is a reimbursable cost, your reimbursement may not be able to be processed.
Business Purpose of Item(s) to be Purchased: Provide a brief statement on the business purpose of the item(s) purchased.
In the table, provide the information requested: description of item(s) purchased, and total cost. The total reimbursement amount will be calculated automatically.
Account Name/Fund Source: Provide the account name or funding source (e.g., Ford grant) to be charged.
Approval Signature: Have the principal investigator (PI) of the funding source sign in this field, authorizing the BSO to charge costs against this account. If the PI has designated another individual to sign approval on expenses for a particular account, that individual should sign in this field (note that the BSO must be informed by the PI in writing that another individual can sign for expenses).
Last updated: 11/1/05
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