Employee Reimbursement Claim Form - Justice Administrative Commission printable pdf download

Employee Reimbursement Claim Form - Justice Administrative Commission

Justice Administrative Commission

Mail or Fax Completed Form To:

JAC QTB Plan Administrator

Qualified Transportation Benefit Program

PO Box 1654

Tallahassee, FL 32302

Employee Reimbursement Claim Form

Toll Free Fax: 866-355-7906

Employee Name

Office/Circuit

Social Security No.

• The regulations require that employees have actually incurred an expense equal to the amount of reimbursement being

sought. (Reimbursements cannot exceed the monthly maximum that has been established by the IRS.)

• An employee’s certification plus a parking receipt will be adequate. The receipt substantiation requirement may be satisfied

with a credit card receipt or the completed JAC Qualified Parking Receipt Form.

•

Employee certification may be sufficient substantiation if “a receipt is not provided in the ordinary course of business.” For

example, where parking meters or coin boxes do not provide a receipt.

•

Requests for transportation reimbursement must be submitted within 180 days of the date which the expense was paid.

***Attach valid receipts for each expense***

Expense Date

Work Location

Parking Receipt

Claim Amount

Parking Receipt Attached

TOTAL REIMBURSEMENT REQUESTED

To the best of my knowledge and belief, my statements in this Reimbursement Request Form are complete and true. I

certify that I have incurred the expenses described above on the dates indicated, that the expenses qualify as valid

expenses under the Plan, and that I have not been reimbursed previously under any other benefit plan, nor do I expect

any of these expenses to be reimbursable elsewhere.

Employee Signature ______________________________________________

Date ________________

For JAC Use Only

Reimbursement Amount

Date In FLAIR

Date Payment Made

Employee Reimbursement Claim Form - Justice Administrative Commission