AS-001 12/96 For Accounting Services Use Only Petty Cash Number: __________ LOUISIANA STATE UNIVERSITY IN SHREVEPORT Reimbursement Request Form Date: Department Request Number: Amount of Reimbursement: Reimbursement to be Made to: PID Number: Budget Account Number Budget Account Name Amount Items Purchased From: Explanation of Reimbursement: Requested By: Date: Approved By: Date: Received By: Date: INSTRUCTIONS FOR FORM AS-001: 1. The reimbursement amount is limited to $150.00. Any amount over $25.00 will be reimbursed by check. 2. This form must be filled out completely. 3. Each request form must be signed by the person making the request (the payee) and by the appropriate supervisor. 4. The space designated for "Explanation" should include a brief statement on the purpose for the expenditure being reimbursed. 5. All documentation (receipts, paid invoices, canceled checks, etc.) should be attached. The original copy of documentation must be included with this reimbursement request. All receipts must include the vendor's name and each receipt must indicate the item purchased. Small receipts or invoices (i.e., cash register tapes) should be taped or stapled to a full sheet of paper to avoid being separated or lost.