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RMS___________ ADAMS COUNTY RSVP
VOLUNTEER TIME & EXPENSE FORM
1301 South 48
th
Street · Quincy, IL 62305
(217) 641-4961
For Volunteers requesting reimbursement:
Please fill out and return to the RSVP office by the 7th
day of each month.
Volunteer Name______________________________
Please print
Month______________________________________
“I CERTIFY for the travel dates listed below that I am a
duly licensed driver authorized to operate a motor
vehicle in my state of residence. I also CERTIFY that I
possess at least the minimum amount of auto liability
surance required by my state of residence.” in
Volunteer signature
REQUEST FOR
REIMBURSEMENT
Volunteer Station & Job
Date
Hours
Meals*
Mileage
*Must have receipt attached for meal reimbursement.
TOTALS
SIGNATURE OF
STATION SUPERVISOR**___________________________________________________________
**Required when requesting reimbursement for mileage or meals.
FOR OFFICE USE ONLY
NAME S.S. # last four digits _ _ _ _
ADDRESS
LOCAL TRAVEL 63001/40401/599005/4040
MEALS 63001/40401/599004/4040
LONG DISTANCE TRAVEL 63001/40401/559001/4040
RSVP DIRECTOR DATE
0.00
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Completed 3 February 2021

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