Name (please print): Email address: Address to which check should be mailed:
To process your reimbursement you MUST do the following:
DIMACS, CoRE Bldg., Busch Campus Attn: Elaine Foley, rm. 430 Rutgers University P.O. Box 1179 Piscataway, NJ 08855-1179
- Attach ORIGINAL receipts
- Sign this form at bottom
- Return reimbursement form and receipts to:
Questions? firstname.lastname@example.org (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.
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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