Reimbursement

Reimbursement Form

Fill out the form below completely. Receipts must be provided for all expenses. Either attach them here, or email to sue@ataxia.org. Accepted file types are: png, jpg, pdf, doc, docx, xls, xlsx, csv.

Reimbursements can be paid via ACH, check, or PayPal. ACH and PayPal are preferred, and will give you the fastest reimbursement. Checks are mailed through our BillPay service and will take 10-15 business days.

Any questions should be emailed to sue@ataxia.org. Thank you!

Please note: Mileage is reimbursed per IRS standard: 65.5 cents/mile.

NAME

ITEM 1 - Description of purchase, date, and amount in USD.

ITEM 2 - Description of purchase, date, and amount in USD.

ITEM 3 - Description of purchase, date, and amount in USD.

ITEM 4 - Description of purchase, date, and amount in USD.

ITEM 5 - Description of purchase, date, and amount in USD.

TOTAL AMOUNT IN USD

RECEIPT 1

RECEIPT 2

RECEIPT 3

RECEIPT 4

RECEIPT 5

SELECT TYPE OF REIMBURSEMENT -
ACH and PayPal are preferred and fastest option. Checks are mailed through our BillPay service and will take 10-15 business days

FOR ACH ONLY - Name of Bank

FOR ACH ONLY - 9 Digit Routing Number

FOR ACH ONLY - Account Number

FOR PAYPAL ONLY - Email Address

FOR CHECK ONLY - Mailing Address - PLEASE NOTE: This method will take 10-15 business days to process.

Reimbursement Form

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