COMMUNITY CONNECTIONS

A STATEWIDE RECREATIONAL LINKAGE SERVICE

 

REQUEST FOR REIMBURSEMENT

 

PLEASE PRINT.  Use the guidelines on the bottom of this form.  Call the statewide office if you have any questions.  USE ONLY ONE FORM PER ACTIVITY.

 

NOTE:  RECEIPT FOR ACTIVITY REIMBURSEMENT OR GAS RECEIPT FOR MILEAGE REIMBURSEMENT MUST BE RETURNED WITH THIS REQUEST

 

DATE:__________________             MEMBER PHONE #:________________________

 

NAME:_____________________________________________  CC ID #____________

 

MAILING ADDRESS:_____________________________________________________

                                   

CITY: ___________________________STATE: ME     ZIP CODE:_________________

 

DATE OF ACTIVITY OR TRIP:____________________                                        

 

ACTIVITY/TRIP TYPE AND LOCATION:____________________________________

 

TOTAL COST OF ACTIVITY/TRIP:_________________________________________

 

AMOUNT OF REIMBURSEMENT REQUESTING:____________________________

 

FOR MILEAGE REIMBURSEMENT: 

ODOMETER READING: START OF TRIP____________ END OF TRIP___________

 

TOTAL MILES TRAVELED:___________________

 

I, (SIGNATURE)____________________________________ CERTIFY THAT I INCURRED THESE EXPENSES FOR THE ACTIVITY/TRIP STATED ABOVE.

FOR OFFICE USE ONLY-PLEASE DO NOT WRITE IN THIS AREA

 

DATE:____________________

 

CC STAFF SIGNATURE:__________________________________________________

BUDGET LINE ITEM: (PLEASE CIRCLE)

            61100-550         ACTIVITY REIMBURSEMENT

            61110-550         MILEAGE REIMBURSEMENT

AMOUNT FOR REIMBURSEMENT CHECK:$____________________________

RETURN TO: COMMUNITY CONNECTIONS-150 UNION STREET, BANGOR, ME 04401

QUESTIONS? CALL (207)941-2998 OR 1-800-834-7150

 

 

GUIDELINES FOR REIMBURSEMENT

 

 

INSTRUCTIONS:

  1. Fill in Name, Mailing Address, Phone #, and Community Connections ID #.
  2. Fill in Date of Activity or Date of Trip
  3. Fill in Activity/Trip Type and Location meaning what you did and where you went to do it
  4. Fill in the Cost of the Activity/Trip
  5. Fill in the amount that you are requesting for reimbursement
  6. Sign the form and send to the address at the bottom of the form

 

** Your signature and a receipt are required for processing.  It takes 2-4 weeks to receive a reimbursement. **

 

Please Remember the Following:

 

Ø      Activity/Trip must be for social/recreational purposes and meet program guidelines for reimbursement.  Call the statewide office if you have questions on whether an activity qualifies. 

Ø      The amount of reimbursement will depend upon past and present usage.  Currently Community Connections reimburses between $5.00 and $10.00 depending on the cost of the activity/trip.  Community Connections does not reimburse for anything that costs less that $5.00 to attend.  The most that the program can help with is $10.00 regardless if your cost exceeds this. 

Ø      The standard reimbursement for all mileage requests out of town is $5.00.  CC does not reimburse for Bus Fare or Cab Fare. 

Ø      CC can only reimburse members of the program.  Reimbursements will not be issued for others that may attend an activity with you. 

Ø      Reimbursements will only be granted for one aspect on your activity.  If CC has helped with a ticket we cannot help with mileage or vice versa.

Ø      Receipts for reimbursement cannot be older than 2 months.  Receipts must be dated and have the cost noted.   Handwritten receipts must include, business name, date, cost of location, and contact name and phone number for verification.  Community Connections does not accept ticket stubs as receipts unless approved first by the statewide office.  Mileage Reimbursement require a gas receipt dated within a few days of the date the trip was made.