* Address  
 
* City          * State * Zip

* Expense 1
Date of Event
Ministry Team / Committee Meeting or Event
Meals/Lodging/Transportation/Etc Expense Description
(Automobile expenses should be calculated at 15 cents per mile.
Bus, train, or plane fare should be actual amount)
   Amount

Expense 2
Date of Event
Ministry Team / Committee Meeting or Event
Meals/Lodging/Transportation/Etc Expense Description
(Automobile expenses should be calculated at 15 cents per mile. Bus, train, or plane fare should be actual amount.)
   Amount

Expense 3
Date of Event
Ministry Team / Committee Meeting or Event
Meals/Lodging/Transportation/Etc Expense Description
(Automobile expenses should be calculated at 15 cents per mile. Bus, train, or plane fare should be actual amount)
   Amount

Expense 4
Date of Event
Ministry Team / Committee Meeting or Event
Meals/Lodging/Transportation/Etc Expense Description
(Automobile expenses should be calculated at 15 cents per mile. Bus, train, or plane fare should be actual amount)
   Amount

Expense 5
Date of Event
Ministry Team / Committee Meeting or Event
Meals/Lodging/Transportation/Etc Expense Description
(Automobile expenses should be calculated at 15 cents per mile. Bus, train, or plane fare should be actual amount)
   Amount

If you have more than 5 expenses to report, please use the printable form. Thank you.

* Total Expenses:

* I understand that this form is to claim my expenses as a DONATION - Please check here to verify you would like to donate your expenses as a gift to the Northwest Region. To recieve reimbursement, press the "Back Button" at the top of your browser and use the PDF document, filling it out and sending to the NWRCC with receipts. Donated mileage will be credited at 14 center per mile (per IRS Regulations).

I would like to recieve my Donation Acknowledgement via the email address above.
I would like to recieve my Donation Acknowledgement via US Mail at the physical address above.

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