Request for Employee Reimbursement and Invoice - Kentucky

Dept. Name:
Contact Person:
Address 1:
Address 2:
Phone #:
Email:
Employee's Signature Date
Total Reimbursement Amount
City/State/Zip:
Date of Expense Amount
Name:
Address 1:
Address 2:
Request for Employee Reimbursement and Invoice (Other than Travel Expenses)
Employee Information Department Information
I certify that the expenses listed above were incurred on behalf and exclusively for the benefits and business purpose of the
University of Kentucky.
Please provide a detailed description of the business purpose of each expense,
provide a complete explanation of why personal funds were used in lieu of the
standard University procurement process (Procurement Card, Purchase Order or PRD)
and attach an itemized receipt for each expense listed.
Address 3:
Page 1/1
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