Compensation Request

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Overview

The form is not complete, and your expenses will not be recorded until you complete all of the required fields, and press the Submit Form button at the bottom. Merely recording your expense data does not count.

Expense Details

Enter details for each expense you wish to claim, then click the Record Expense Data button. Repeat for each expense you have for this time period.

Duty Performed - Choose from the list. If 'Other' is selected, you must type in what exactly was done.

Location - Where was this duty performed? (i.e. office, restaurant, etc)

Miles Driven - If you drove your personal vehicle to complete this task, specify the round trip mileage.

Authorization

Final authorization will be provided when you sign in the space provided, by either using your mouse on your desktop computer, or with your finger when using a tablet or your phone.
*Hint: When using a mobile device, turn it sideways to provide more signing space.

Please complete this form to receive reimbursement for duties performed.

Period Covered

Individual Making Request

Commissioner

Expense Details

Date
Duty Performed
Location
Mileage
Time Spent
Time Started
Time Ended
Date Duty Location Mileage Time

Expense Totals

Total Days Reported 0 @ $161.00/day = $0.00
Total Mileage 0 @ $0.67/mile = $0.00

Authorized by

Turn your device sideways to provide a larger signature area.

I certify under penalty of perjury that the foregoing is a true and correct statement of necessary expenses incurred by me, and that I have not received payment for these expenses.

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Printed Name
Date