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Justification Form
This form is required for all expense reimbursements that are submitted in excess of 60 days after the expense was incurred.
Employee name: ___________________________________
Employee ID#: ___________________________________
Reimbursement amount: ____________ DPA/Travel Voucher # ____________
Date reimbursement request was submitted: ____________________
Reimbursement type: (circle one) Travel Moving Misc. Expense
Please complete the applicable section below.
I do not have justification for late submission of expenses, please add the allowable reimbursement amount to my W-2 on the next payday in accordance with payroll cutoff dates.
OR
I am requesting an exception to the 60 calendar day rule for the following reason(s):
NOTE: Misplaced receipts, lack of awareness of the policy, etc are not valid reasons for an exception.
Employee signature (required): ____________________________________ Date: ____________
Business Office Use Only
To Payroll _____________________
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