CREATE Reimbursement Request

FACULTY & STAFF REIMBURSEMENT REQUEST FORM

Complete this form to request purchase approval for CREATE account purchasing only.

NOTE:

Items must be received before submitting the reimbursement.
If you plan to submit a receipt for office supplies, chemicals, software, or any other items that a MarketPlace Vendor could supply, your request will be denied, and you will NOT be reimbursed.

Name of Person Completing this Form *

TxSt Email Address: *

Are You Employed By TXST *

Select

If you're not employed by TXST, please input your mailing address

If ordering on behalf of another, please list their name below: *

Associated Project Name & PI *

Category of Order

Category *

Is this reimbursement for food:

Yes

If category is not listed above, explain here.

Reason for Reimbursement

Why was this not purchased through Market Place?

Be Specific! If the purchase was made for research - make sure to include the type of research, room number, or any other pertinent details.

Reasoning: *

Receipt Information

Item(s) purchased from (ex. Amazon, etc)

Date of Purchase *

Date Item(s) Received: *

Amount of Purchase: *

Is this a reimbursement for food: *

If yes, please list the attendees (make note of non-TX State attendees) *

Funding Information

If using a specific grant/personal account for reimbursement, please specify. Enter the Source of Funds, and complete the Cost Center/Fund/Account information in the fields below.

Source of Funds: *

IF Other, has a reimbursement form for ISOE been completed? If No, Explain: *

*Express permission from CREATE director required for Other Funding

Required: Cost Center / Fund / Account Number:

Please provide account number to expedite the reimbursement

Upload your receipt and bank/card statement below as a PDF

You will not be reimbursed for sales tax
To help with processing, you must attach a snapshot of the charge from your bank/card statement (the card/bank statement that contains this purchase in your name)
Required information includes your name, relevant charge, and the last four digits of the relevant card, if available. Please black out all other info

Receipt: *

Bank/Card Statement: *

Certification Statement

By checking this box, I acknowledge that this serves as my signature and validation of the expenses listed on the 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 or by any other means. *

I certify that the above statement is true.

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