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Public\departments\finance\forms\Reimbursement Form-FY 2016 Revised 6/8/2015 City of Salem, Massachusetts FY 2016 REQUEST FOR REIMBURSEMENT ALL REIMBURSEMENTS MUST BE SUBMITTED ON A BASIS Name: Vendor Department: Date: PO Number: Invoice REIMB . DESCRIPTION AMOUNT Seminars/ Meetings – Etc: Mileage: X $.575 City 7/1/15 thru 6/30/16 $.565 School 7/1/15 thru 8/31/15 $.575 School 9/1/15 thru 8/31/16 Destination – Submit copy of conference flyer: Parking/Tolls: Registration Fees/Membership Meals - Detailed Receipts required: REASON: Outside Services Rendered (Tutoring – Field Trips – etc:) REASON: Other REASON: TOTAL AMOUNT DUE Department Head Signature: ALL RECEIPTS, TAPES, MILEAGE SHEETS ETC., ARE TO BE ATTACHED TO THIS FORM FOR REIMBURSEMENT. WE WILL NOT REIMBURSE SALES TAX!