Wage & Expense Form | Laestadian Lutheran

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Wage & Expense Form

First name

Last name

Phone

Email

Select an Address

Reimbursement Format

Check, by mail

Direct Deposit

Canadians, select this option

Routing Number

Account Number

Event Type

Position

Location

Camp Facility

Camp

If "other", what is reimbursement for?

Start Date

End Date

Eligible Wages

Travel Expenses:

Mileage (mileage rate: $0.49/mile)
Airfare
Vehicle rental
Accommodations

Travel Expenses

Total you wish to collect (at most Wages + Travel)

Additional Notes

Upload PDF (if applicable)

Upload PDF

Upload supported file (Max 15MB)

Upload Image (if applicable)

Upload Image

Upload supported file (Max 15MB)

Thanks for submitting!

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212 West 3rd Street

Monticello, MN 55362

763-479-2422

info@llchurch.org

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