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
Suzanne Delle
KCACTF Region II Chair
2545 Midpine Drive
York, PA 17404

Additional Comments