Finance & banking
Expense reimbursement claim template (US)
A general template under US law. Laws differ from state to state, so check it against your state's law or with a lawyer licensed there. We are not a law firm and do not give legal advice.
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Preview — US standard
Expense Reimbursement Request
Employee: Employee Name
Employee ID: Employee ID
Department: Department
Manager: Manager Name
Period covered: Start Date to End Date
Business purpose: Business Purpose of the Expenses
Expenses
| Date | Description | Category | Amount (USD) |
| --- | --- | --- | --- |
| First Expense Date | First Expense Description | First Category | $First Amount |
| Second Expense Date | Second Expense Description | Second Category | $Second Amount |
| Third Expense Date | Third Expense Description | Third Category | $Third Amount |
| Fourth Expense Date | Fourth Expense Description | Fourth Category | $Fourth Amount |
Mileage
Business miles driven in a personal vehicle: Miles Driven miles at $Mileage Rate per mile = $Mileage Total. Trip log attached: Yes or No.
Summary
• Total expenses: $Total Expenses
• Less cash advances received: $Advances Received
• Amount due to employee: $Amount Due to Employee
• Amount due to company: $Amount Due to Company
Employee Statement
I certify that these expenses were incurred by me for Company business, that they are accurate, that receipts are attached for every expense of $Receipt Threshold or more, and that I have not been and will not be reimbursed for them from any other source. This report is submitted within Submission Deadline Days days of the expenses, as Company's accountable plan requires.
Employee signature: Employee Signature
Date: Employee Signing Date
Approval
Approved by: Approver Name, Approver Title
Signature: Approver Signature
Date: Approval Date
Reimbursement paid on: Payment Date, by Payment Method