Expense Reimbursement Form (FDSS)

Expense reports are due by the 5th of the month, following the month in which expenses were incurred.
Upload all supporting receipts and data.
Once approved by your supervisor, reimbursement checks are typically issued the week of the 15th.
If expense reports are late (submitted after the 5th) they will be paid on Friday at the end of the month.
If you have expenses for the CURRENT month that are over $150, and submit them by the last Monday of the month, they will be paid out by the last Friday of the month.

This report is for expenses incurred in the month of: *

If you are reporting expenses for more than one month, submit a separate report for each.

Your Name

Name*

First NameLast Name

Your E-mail*

Department/Cost Center*

Approver's E-mail*

Must be a DPI employee (with DPI email address, not gmail, yahoo, or other non-company suffix).

Has your address changed (or is this your first Expense Report)?*

YesNo

New Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any purchases/expenses to report (other than mileage, parking, or cell phone costs)?

YesNo

Expenses

Expense Total

This field automatically updates, do not enter data.

Purchase/Expense Total : {expenseTotal}

Do you need cell phone bill reimbursement for business use ($60 per month)?*

YesNo

How many months?

Cell Phone Bill Total

Cell Total : {cellPhone}

Do you have mileage to include?*

YesNo

To log/record your mileage, please download this mileage tracking spreadsheet (found on the Dispatch) and submit a copy as well as any parking receipts with this Expense Report.

Enter Total Miles (must match tracking spreadsheet).

(the current IRS tax rate calculates behind the scenes)

Mileage Reimbursement Amount (total miles x .70).

Mileage Total : {mileageReimbursement}

Total Parking Fee $ (upload receipts)

Receipts, Mileage Support, and/or Other Related Documents

Comments/Notes

Reimbursement Total : {totalReimbursement}

TOTAL REIMBURSEMENT

This field automatically updates, do not add data.

Affirmation:*

I certify that all information I have entered above is accurate and supported by documentation. I understand that submitting fraudulent expenses/mileage will result in disciplinary action, up to and including termination and/or legal action.

Signature*