Respondent Reimbursement Form

Respondent or Artist Seeking Reimbursement

Name *

Email *

Work Phone

Cell Phone *

Send Reimbursement to:

Address Line 1: *

Address Line 2:

City: *

State *

Zip *

Reimbursement Category

Production Information: (One production per form)

Production name: *

Date:

Location (City, State): *

Producing Institution: *

Associate Production(s): Online Response sheet(s) completed? *

Yes

Participating Production(s): Online Response sheet(s) and Written Response sheet completed? *

Yes

Other Reimbursements (One type per form)

Reimbursement For: Select best option

Other: Explain

Date(s)

Travel Information (receipts required):

Total Miles Driven in Personal Car (Numbers only)

Personal car/gas expense @ $.40 per mile

Do you have additional expenses?

Yes

Tolls (Dollar Amount Only)

Parking (Dollar Amount Only)

Taxi/Uber/Lift/Rideshare (Dollar Amount Only)

Plane/Train/Bus fare (Dollar Amount Only)

Other (Dollar Amounts Only)

Other (Description)

Total:

Mapquest or googlemaps link here

Donation

As a qualifying non-profit, expenses donated back to the Region may be tax deductible. Letters will be sent once per year, after regional festival for tax purposes. Please consult with a tax professional if you have questions.

I would like to donate back my expenses to Region 2.

YES, Please

Please check all that apply:

I have sent my receipts via "snail mail?"

Yes

N/A

Upload scanned receipts (one file per box):

Maximum file size: 256MB

Note that reimbursement will not be made until all required response forms have been received (if applicable) and expenses have been approved.

Send receipts via mail to

Additional Comments

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