Name (please print):

             Email address:

Address to which check should be mailed:



To process your reimbursement you MUST do the following:

Attach ORIGINAL receipts
Sign this form at bottom
Return reimbursement form and receipts to:
        DIMACS, CoRE Bldg., Busch Campus
        Attn: Elaine Foley, rm. 430
        Rutgers University
        P.O. Box 1179
        Piscataway, NJ 08855-1179
       
Questions? epfoley@dimacs.rutgers.edu (908) 445-4631
(Note: reimbursements take approximately four weeks to process.)

 Airfare (U.S. airline only): 
Mileage (@25 cents per mile): 
    (please list start point: 
           and destination.): 
Other costs (describe item and enter amount in same box):
Item#1:
Item#2:
Item#3:
Item#4:
Item#5:
Item#6:
Item#7:
Item#8:


I certify that the attached receipts are appropriate and accurate.

 


Signature

 

 
You may use this as a template - fill in the information, print it out, sign the 

form, then mail it along with your original receipts, to me.
 

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