DISASTER RELIEF REIMBURSEMENT FORM

Illinois Baptist Disaster Relief Reimbursement Request

Name of person to whom the reimbursement will be written:

First Last

Address

Street Address Address Line 2 City State ZIP Code

Callout/Event/Meeting:

Dates Held:

Round trip travel from:

To:

Total vehicle mileage*:

Rate (see bottom of page) =

Total number of passengers in my vehicle:

Trailer

Yes Trailer

No Trailer

Pre-approved charges for parts, repairs or miscellaneous (with attached receipts)

Parts Receipts

Drop files here or

Max. file size: 250 MB.

Pre-approved Lodging (with attached receipts)

Lodging Receipts

Drop files here or

Max. file size: 250 MB.

Pre-approved Meals (with attached receipts)

Meal Receipts

Drop files here or

Max. file size: 250 MB.

As Payee, I request a reduction of reimbursement as a donation to IBDR. ($ amount)

As Payee, I request a reduction of reimbursement because I received partial funding from another funding source. ($ amount)

Account number 3610-000-000 Total reimbursement request:

Requested By (Signature)

IBSA Missions Director:

a. A vehicle must have a minimum of 2 people for
b. Single driver vehicles will only be allowed with prior approval from the State

a. A vehicle must have a minimum of 2 people for
b. It is expected that a unit will include one-unit trailer, and in some situations one piece of large equipment. Additional equipment requires approval from the state director prior to their departure to the

Phone

This field is for validation purposes and should be left unchanged.