An employee reimbursement form is issued by a company for reimbursing expenses like medical, house rent, travel, etc. The applicant needs to fill in his personal details, details of the expenses incurred like dates, amount, purpose, etc in separate lines, and finally the total amount incurred need to be mentioned. The sample given below can be used by an employee to reimburse any general expenses with the company.
Sample Employee Reimbursement Form
Details of the employee
Full name of the employee: ____________________________________________________
Home address line 1: _________________________________________________________
Location: ______________ State: _______________ Zip Code: ____________
Mobile number: _________ E-mail id: ___________ Extension: ____________
Details of the Reimbursement
1. Expense incurred for: ______________________
Amount incurred: ______________________
From Date: ____________ to Date: ___________
2. Expense incurred for: ______________________
Amount incurred: ______________________
From Date: ____________ to Date: ___________
3. Expense incurred for: ______________________
Amount incurred: ______________________
From Date: ____________ to Date: ___________
Total amount (In number): _________________________
Total amount (In words): ______________________________________________________
Signature of the employee: __________________________
Date of submission: __________________________
Download Employee Reimbursement Form in Word Format