Revised9.2018
EMPLOYEE REIMBURSEMENT
REQUEST
Employee Legal Name: UA ID#:
Employees signed up for Direct Deposit through UAOnline (separate from Payroll Direct Deposit) will receive
reimbursement via Direct Deposit. Otherwise, a check will be mailed to the address on file with HR.
Description of Purchase:
Account(s) to be charged
:
FUND ORG ACCT AMOUNT $
FUND ORG ACCT AMOUNT $
TOTAL $
By signing below, I hereby certify that this is a true and accurate business expense that has not previously been
reimbursed.
Signature of Employee requesting reimbursement:________________ Date:
By signing below, I hereby certify that this is a true and accurate business expense that is approved for reimbursement.
Signature of Dean/Director/Budget Approver: Date:
By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and
the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and
conditions of the award.
Signature of P.I. (if applicable):______________________________________ Date:___________________
***Accounts Payable Use Only***
Budget Check___________________________________ Document No. ____________________________
AP Manager Approval_____________________________ Invoice__________________________________
This form cannot be used for travel reimbursement. Do NOT enter a requisition in Banner.
Attach the original itemized receipts and appropriate back-up then forward to Accounts Payable.
Approved UAA Representational (Rep) Expense Allowance Forms are required for
4008/4018/4038/8115/8210 expenses. Please see www.uaa.alaska.edu/aptravel for information
about the types of purchases that can be reimbursed with this form.
