Revised 04/27/18
Department:
Organization No.:
Commodities Acct. No.:
Staff Member to be Reimbursed:
(Last Name) (First) (Middle Initial)
Staff Member Address:
MUW ID Number:
City Where Expenditure was Made:
Names and Titles of Persons Involved:
Purpose and Nature of Expenditure:
Amount of Expenditure:
*Attach receipt to the back of this form. Receipt should be ITEMIZED*
*Credit card slips with totals only are not itemized and, therefore, not acceptable.*
*Tips should be kept to 20%; otherwise they will be adjusted before payment.*
Date of Expenditure:
I certify that the above expense is necessary in order to conduct official university business that could not
have been accomplished otherwise.
(Signature) (Date)
APPROVED:
Budget Manager:
(Signature) (Date)
Executive Committee Member:
(Signature) (Date)
University Accounting:
(Signature) (Date)
MISSISSIPPI UNIVERSITY FOR WOMEN
REQUEST FOR REIMBURSEMENT OF PERSONAL EXPENDITURES
INCURRED WHILE CONDUCTING OFFICIAL UNIVERSITY BUSINESS
click to sign
signature
click to edit
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