Reimbursement - National Ataxia Foundation

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Reimbursement Form

Fill out the form below completely. Receipts must be provided for all expenses. Either attach them here, or email to finance@ataxia.org. Accepted file types are PNG, jpg, pdf, doc, docx, xls, xlsx, and csv. The Finance Department will contact you if any additional information is required.

Reimbursement requests must be submitted within 30 days of the expense. Late submissions may be subject to rejection, so timely submission is essential.
Please ensure all receipts are attached to the reimbursement request.
Receipts must provide an itemized breakdown of expenses and proof of payment.
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.
For ACH: Please ensure you provide the correct bank account information to prevent the funds from being sent to the wrong account.

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

Please note: Mileage is reimbursed per IRS standard: 70 cents/mile.

NAME

EMAIL

EVENT NAME (if applicable)

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.

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