Evangelical Lutheran Church in America

OFFICE

Northern Illinois Synod

Evangelical Lutheran Church in America

103 W. State St., Rockford, IL 61101-1105

(815) 964-9934

Name: ______

Address: ______

______

(City) (State) (Zip)

Auto Miles ____ at 53.5¢ per mile: $______

Tolls or Parking Fees: $______

Meals or Food: $______

Lodging: $______

Other (must specify)______: $______

Total Expenses: $______

Reimburse for above, or

Approve and return form to verify deductible contribution

·  (Please note: If using this voucher as verification of an income tax deduction, per the IRS you may claim only 14¢ per mile as a charitable contribution. Therefore, change the 53.5¢ figure above to 14¢ per mile before calculating your expense.)

NOTE: Per IRS Publication 463, all reimbursements must include “an adequate accounting of expenses, (i.e. receipts and records of mileage) and must be submitted within 60 days of the expense(s) occurring.” Also, should an individual be audited, s/he must be able to provide documentation of mileage.

Date / Beginning / Ending / Business / Personal
Mileage / Mileage / Miles / Miles

______

(Sub-Committee or Task Force) (Place of meeting) (Date)

I certify the above to be true and correct ______

(Signature of Individual Payee)

Equipment & Maintenance - Rockford / Equipment & Maintenance – Rock Island
__ 175-60020 / Equipment – Computers, etc. / __ 175-60205 / R.I. – Equipment
__ 175-60023 / Equipment Maintenance / __ 175-60210 / R.I. – Equipment Maintenance
__ 175-60025 / Equipment – Labor
Occupancy – Rock Island
Occupancy - Rockford / __ 200-60020 / Occupancy Expense – R.I.
__ 200-60010 / Occupancy Expense – Rockford
Office Expense – Rock Island
Office Expense - Rockford / __ 250-60230 / R.I. – Office Supplies
__ 250-60010 / Bank Charges & Other Fees / __ 250-60240 / R.I. – Postage
__ 250-60014 / COMM – Making Christ Known / __ 250-60250 / R.I. – Printing
__ 250-60016 / COMM - Website / __ 250-60270 / R.I. – Telephone
__ 250-60030 / Office Supplies
__ 250-60040 / Postage / Unbudgeted Expenses
__ 250-60050 / Printing / __ 500-60020 / Consultation Team Expense
__ 250-60060 / Subscriptions & Dues / __ 500-60050 / Miscellaneous Expense
__ 250-60070 / Telephone / __ 500-60060 / Moving Expense
__ 250-60072 / Telephone – Electronic Network / __ 500-60070 / Seminars/Workshops
Continuing Education - Staff
__ 400-60030 / Continuing Ed - Bishop & Assistants
__ 400-60220 / Continuing Ed - Support Staff