Employee Reimbursement Form

July 8, 2011

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

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