Request for Expense Reimbursement

Request for Expense Reimbursement

  • Due by the 1st and the 16th of every month. Use one form per client, event or reason. Original Receipt required; Image okay.
    (You may alternatively print the PDF form for manual submission.)
  • How to use the form

    To request reimbursement for expenses such as parking and supplies or for miles driven. please list only one item per row. When listing miles for reimbursement, please do not add a number in the cost field as it will add up automatically in the formula below. Use one line per expense or trip.

    When filling out the list,

    • Item Type - Write a descriptor like: Mileage, parking or supplies
    • Description - List specifics like destination, location or specific items
    • Miles - List the only the number of miles driven (if you are using that row to report miles)
    • Cost - Fill in this amount for any expense except for mileage

  • DateTypeDescriptionMilesCost 
    Add a new row
  • Mileage Total: 0.00

    Mileage Reimbursement: $0.00 ($0.54 per mile)

    Expense Subtotal: $0.00

    Total: $0.00

  • Sinai In-Home Care Expense Reimbursement Policy


    • What we reimburse: SHC reimburses for mileage, parking and supply expenses that have been previously authorized only by a supervisor or in a Service Plan. Use one form per client, event or reason. Use one line per expense or trip. Send original receipt which is required. An image of the receipt is okay if submitted by email.
    • When to submit request by: Reimbursements must be submitted to the SHC office on a timely basis. For any expenses incurred between the 1st and 15th of the month, signed forms are due to the office before or by the end of the day on the 16th of the month. For any expenses incurred between the 16th and the last day of the month, signed forms are due to the office before or by the end of the first day of the next month. Reimbursements to staff will be made on the next following payday. If expense reimbursement forms are not submitted by the deadline, there is a risk of not being reimbursed at all.


  • By checking the box below, I am stating that the reimbursement form is an accurate and true accounting of my expenses in accordance with authorized expenses and reimbursement policy. Further, I understand that any falsification of records is not acceptable to SHC and may be grounds for termination.