2019 Expense Reimbursement Request Online Form
Co-Dependents Anonymous, Inc.
Thank you for donating your time in service to CoDA, Inc. This form is for you to use to receive reimbursement from CoDA, Inc. for expenses you incurred doing service work. Remember that you are being reimbursed for your expenses with other members' 7th tradition donations. If you received free meals or didn't spend all of your Per Diem, consider reducing the amount of your Per Diem claim or making a 7th tradition donation at the bottom of the form.
The Finance Committee of CoDA, Inc.
Fields with an * are required fields.
Fields with ** require a numerical value. (If zero, leave blank. Note: Letters where numbers are expected will delay processing as they will need to be manually removed.)
Currency of Expense
What currency did you use to pay for the expenses you are claiming on this form? (Use separate forms for separate currencies.) If your choose "Other," please specify the currency in the "Notes" box located near the bottom of this form.
British Pounds Sterling
Other see "Notes" box
Note to International Travelers
If you had expenses in a second currency, please click on this link
for special instructions.
About the person who will receive the reimbursement.
(if none, type in "none")
Mailing Address (line 1)
Line 2 (optional)
or reason for reimbursement
Committee Face to Face
CoDA Service Conference
Specify other "Meeting Purpose" here:
What budget area will pay for these expenses?
Events Split Conf/Conv
Events Conference only
Events Convention only
General Fellowship Services
Hospitals & Institutions (H&I)
Issues and Mediation Com (IMC)
Service Structure Committee (SSC)
Spanish Outreach (SPO)
Translation Management (TMC)
World Connections Committee (WCC)
TRO (Travel Reimbursement Opportunity)
Starting Service Date
Date of the first meeting you are expected to and did attend.
Ending Service Date
Date of the last meeting you are expected to and did attend.
Your specific travel information
Travel start TIME
What time did you leave your home to start your travel for this trip. If you had personal time added to the trip what time would you have left if only traveling for CoDA, Inc.
Before 7:30 AM counts as a full day for Per Diem, otherwise you are eligible for .75 day on your travel day.
Before 7:30 AM
7:30 AM or after
Travel start DATE
What day did you start your travel? If you traveled early for personal purposes, enter the date you would have traveled if only traveling for CoDA, Inc.
Travel return TIME
What time did you arrive at your home to finish your travel for this trip. If you had personal time added to the trip what time would you have returned if only traveling for CoDA, Inc.
After 6:00 PM counts as a full day for Per Diem, otherwise you are eligible for .75 day on your travel day.
After 6:00 PM
6:00 PM or before
Travel return DATE
What day did you finish your travel? If you traveled later for personal purposes, enter the date you would have traveled if only traveling for CoDA, Inc.
Expenses being claimed
This section is the final amounts in each category that you are claiming. In the next section we will ask for some more detailed information to support the amounts you claim.
h. Airline Cost **
Total cost of your ticket for CoDA travel. Do not include any extra legs of travel that were done for personal business. Include copy of ticket receipt. **
i. Total hotel cost **
Do not include any personal expenses, phone, movies, meals, etc. Attach a detailed hotel receipt. **
j. Per Diem total **
For 2019: Face to Face rate is $55
CoDA Service Conference is $66
Receipts for meals are not required. **
Please reduce Per Diem total if you received free meals and the Per Diem total exceeds your actual expenses for meals and tips. Per Diem is broken down into the following amounts:
Meeting, Total, Breakfast, Lunch, Dinner, Misc/tips
Face to Face $55 T, $13 B, $14 L, $23 D, $5 M/T
Service Conf. $66 T, $16 B $17 L, $28 D, $5 M/T
Check this box if you purposely reduced your Per Diem total to compensate for free meals or reduced expenses.
k. Total for mileage **
2019 mileage rate is $0.58 per mile
Miles driven x $0.58 (Include a map or log if mileage is over 51 miles) **
l. Parking cost **
Prorate if some of the trip was for personal reasons. (Include receipt if over $30.) **
Other Travel costs:
Include in this total costs like baggage fees, local transportation (other than personal automobile), etc. Receipts required for expenses over $30.00 per expense. (List in details section if total is over $30 for transactions claimed without receipts.)
m. Total Other travel costs **
Total cost for miscelanious expenses. **
n. Total travel cost being claimed **
Sum of boxes h-m
Make sure you answer the supporting questions in the next section and then carry this total down to box r or s after you review possible adjustments in boxes n, o, & p **
You are not done yet!
Please support your claims in the next section, and then make possible adjustments in boxes o-q below. You will need to enter the amount you claim in box n above to box r or s below, attach receipts, and submit the form with your "signature" at the bottom.
Supporting information for amounts claimed above
Travel method (Primary)
(Related to box h. above.)
If other than by air, please provide rationale and what copy of what a flight would have cost in this box if travel time would have been more than 4 hours by other means.
Name of Hotel(s) & location
(Related to box i. above.)
Lodging - Number of nights **
Rate / night / person
Enter average rate per night including tax & fees.
(For CSC the reimbursable rate is $???? + taxes or less/ person double occupancy.) **
Information about your Per Diem claimed
Number of days of Per Diem requested **
(Related to box j. above.)
Travel days usually are .75 day unless started early or finished late. (enter only a number) **
Face to Face / CoDA Service Conference
(Related to box k. above.)
Example: Drove daily to meeting. 10.3 miles RT, 4 times, + drove trusted servants to dinner one night.
If over 51 miles, include a map or log with starting and ending points
Miles driven (total) **
(enter only a number) **
(Included in box m. above.)
Example: one bag round trip $25 each way = $50
Local transportation (other than by personal automobile)
(Included in box m. above.)
What is the explanation for Local transportation costs. Example: Metro from home to airport, $7.50; XYZ Shuttle from Airport to hotel, $20.55.
Misc other travel exp: Explanation
(Included in box m. above.)
List other expenses claimed with explanation. (Include individual transactions under $30 not supported by receipts if total is over $30.)
Adjustments to Total Expense Reimbursement Request
You are not done yet!
Enter the amount you are due in box r. or amount to be returned to CoDA in box s. below.
o. 7th Tradition Donation
If you would like to donate some of your reimbursement back to CoDA, please enter the amount of your donation here. **
If you received an Advance, enter your Tracking Number here:
p. Amount of Advance **
q. Amount on CoDA, Inc.'s credit card
If your hotel was paid for by CoDA, enter amount paid on your behalf by CoDA. This may or may not be the same as in line l above. **
r. Total amount owed to member
If n is greater than the sum of o, p, & q, enter the amount due member n-(o+p+q) **
s. Amount due CoDA
If the sum of o, p & q is greater than n, then enter the difference due CoDA here. (o+p+q)-p **
Note: Amount Due CoDA, Inc.
After review of your claim, you will be contacted with the approved amount you owe CoDA, Inc. and you agree to send a check for (or go online and pay) the amount due in a timely manner. Checks can be sent to:
Fellowship Services Office
P.O. Box 33577
Phoenix, AZ 85067-3577
Upload copies of your receipts here. (Food receipts are not necessary.) Receipts for $30 or less are not necessary, but appreciated. Make sure that you explain any amount claimed that is not accompanied by a receipt.
Flight, etc. in support of Box h.
Hotel detailed receipt in support of Box i.
Map or mileage log if over 55 miles in support of Box k.
Parking receipt if over $30. in support of Box l.
Receipts over $30 claimed in Box m.
If you do not have all of your receipts, you may forward them by email to firstname.lastname@example.org (This will slow down the processing of your request.)
If you have any non-travel Expenses to submit, click here.
You will have the option to fill in a second form after you submit this one. By clicking here, we will link the two forms together. Look for the link to the second form in the acknowledgment of submission of this current form.
Are there any special things that we need to know in processing this Expense Reimbursement Request?
By typing my name in the "Signed by" field and submitting this form with attachments, I attest that I incurred the above expenses serving CoDA, Inc. and that this form is complete and accurate to the best of my ability. I agree that I will provide further information if requested for the purpose of clarifying or explaining the above reimbursement requests. If I fail to provide requested additional information in a timely manner, I understand that I will forfeit the reimbursement in question.
I further understand that this reimbursement is subject to the Expense Reimbursement Policy and the Expense Reimbursement Approval Procedure which is available at the CoDA, Inc.'s website
Check this box and we will send you a copy of what you submitted.
(We can do this if you leave the email address err@CoDA.org in the field below.)
In the next hour you should receive an automated email from the Finance Committee sent from CoDALou@Gmail.com. This will have an assigned tracking number in the subject line. We will forward a separate Confirmation email from SmartSheet to you with the a copy of the information you submitted. If a printer is available to you, you may want to print this form before you submit it to retain all the instructions as well as the information.
Please, do not unclick the box below!
Send me a copy of my responses
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