FIT Reimbursement Form
*Submit reimbursement form and all receipts within 30 days of event.
Jeopardy/Cotton Education Event
Saturday, October 5th, 2019
FIT Full Name*
First Name Last Name (MD, DO, etc)
Program Director Full Name*
First Name Last Name (MD, DO, etc)
Fellowship Program*
Mailing Address for Reimbursement Check*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
FIT E-mail*
Eligibility Certification:*
I certify that the FIT will not be double reimbursed.
Please enter your expense information in the fields below.
Date(s) Incurred:*
Mileage @ $0.545 per mile
example: 25 miles x $0.545 = $13.63
Tolls
enter dollar amount
TOTAL REIMBURSEMENT AMOUNT*
IRS REGULATIONS REQUIRE THAT ORIGINAL RECEIPTS
BE ATTACHED FOR ANY EXPENSE ITEMS OF $25.00 OR MORE
Attach Receipts:
Browse Files
Cancelof
These expenses were incurred by me in the fulfillment of my official duties.
Personal expenses have been excluded.
FIT Signature:*
Clear
Should be Empty:

FIT Reimbursement Form