Faculty and Staff Reimbursement Request Form

This form is for reimbursements within the College of Science and Engineering Dean’s Office only.

This form is NOT for a Travel Reimbursement Request.

Please note:

Sales Tax will not be reimbursed
Alcohol will not be reimbursed
Tips above 20% of a meal's sub-total will not be reimbursed
Software or Hardware reimbursements cannot be processed without proper ITAC, ISO, and EIRAC reviews and approvals

Name *

NETID *

Texas State Email Address *

Purchase Details

Vendor Purchased From: *

Example: HEB, IEEE, etc.

Receipt/Transaction Date: *

Reimbursement Amount *

Please subtract tax if there is any on the receipt

Purchase Description *

Example: IEEE Membership Renewal, Article Processing Fee, Conference Registration, etc.

Reason for Purchase: *

How this helps your research, why you took a group to lunch, details of renewal or publication, etc.

If this is a meal reimbursement, please list all attendees of the meal:

Source of Funds: *

Please provide the account numbers if known. If not, please use account nama ie: Start Up

Upload a copy of your itemized receipt: *

Certification Statement

Please read and agree to the certification statement. *

By checking this box, I acknowledge that this serves as my signature and validation of the expenses listed on this reimbursement request with the corresponding receipts attached. I certify that the expenses are correct, were paid with my personal funds, and have not been paid or reimbursed previously by the university nor by any other names.

Approval *

I certify that the above statement is true.

If you happen to see this, do not fill this field.

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CoSE Reimbursement Request

Faculty and Staff Reimbursement Request Form

Purchase Details

Certification Statement