Expense Reimbursement Form
Itemised reimbursement form for employee out-of-pocket business expenses.
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ACME CORPORATION
EXPENSE REIMBURSEMENT FORM
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Employee: Jordan Alex Taylor ID: EMP-1138
Department: ENG-PLAT-220
Approving manager: Priya Patel
Submission date: June 19, 2026
Period covered: May 1–14, 2026
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OVERALL BUSINESS PURPOSE
Customer-success visit to Acme's top-3 enterprise account in Seattle. Two days on-site for technical review and quarterly business review. Meals with customer team and internal travel.
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EXPENSE LINES
2026-05-08 | Travel — Air | Alaska Airlines | PDX-SEA round trip | 268.40
2026-05-08 | Travel — Ground | Uber | PDX airport to Acme Seattle office | 54.20
2026-05-08 | Meals | Pyramid Brewing | Working lunch with customer team (4 attendees) | 142.50
2026-05-08 | Lodging | Marriott Downtown Seattle | 1 night, room + tax | 218.00
2026-05-09 | Meals | Local cafe | Breakfast (per diem) | 18.00
2026-05-09 | Travel — Ground | Uber | Hotel to airport | 32.10
2026-05-09 | Travel — Parking | PDX | 2 days economy parking | 36.00
Subtotal (line items): $769.20
Mileage: 0 mi × $0.70/mi = $0.00
GROSS TOTAL: $769.20
Less: cash advance received: ($0.00)
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REIMBURSEMENT REQUESTED: $769.20
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PAYMENT METHOD
► ACH to direct-deposit account on file
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EMPLOYEE CERTIFICATION
I certify that:
(a) The expenses above were actually incurred by me on behalf of Acme Corporation.
(b) Each expense had a valid business purpose.
(c) Receipts are attached for every expense exceeding $75 (Treas. Reg. §1.274-5), and for all lodging regardless of amount.
(d) None of these expenses has been or will be reimbursed by another party.
(e) I have not received personal benefit beyond what is incidental to the business purpose.
_______________________________ Date: June 19, 2026
Jordan Alex Taylor
APPROVAL
_______________________________ Date: ____________________
Priya Patel (Approving manager)
About this template
An expense reimbursement form formalises employee reimbursements under what the IRS calls an "accountable plan." Three requirements turn employer reimbursements into non-taxable income (rather than wages added to the employee's W-2): (1) the expenses must have a business connection, (2) the employee must substantiate them within a reasonable time (usually 60 days from the expense), and (3) any excess advance must be returned within a reasonable time (usually 120 days). When all three are met, reimbursement is non-taxable to the employee and fully deductible to the employer. Skipping the substantiation step turns the reimbursement into wages — taxable to the employee, plus payroll taxes for both employer and employee. The substantiation requirement under Treasury Regulation §1.274-5 is specific: receipts for any expense over $75, all lodging regardless of amount, contemporaneous records of business purpose, date, location, and attendees (for meals). Common reimbursable categories include travel (air, ground, parking), lodging, meals (50% deductible at the company level under TCJA, but typically 100% reimbursed to employee), supplies, conference fees, mileage at the IRS standard rate, and per-diem for meals where the company elects. Receipts are typically scanned and attached to the form; many companies use expense-management software (Expensify, Brex, Ramp, Concur) that handles the workflow, but a paper or PDF form remains useful for small businesses without dedicated tooling and for off-system expenses.
When to use it
- Employee out-of-pocket expense for business purposes.
- Reimbursable travel, meals, lodging, supplies, mileage.
- After business trip, conference, or customer visit.
- Per-period reimbursement (weekly, semi-monthly, monthly).
- When operating without expense-management software.
What to include
- Employee identification and department.
- Approving manager.
- Period covered and overall business purpose.
- Itemised expense lines with date, category, vendor, description, amount.
- Mileage with calculation.
- Cash advance offset.
- Employee certification + manager approval.