Non-Travel Expense Reimbursement Request Online Form

Co-Dependents Anonymous, Inc.

Version 8.0 nt 01/16/18

Fields with an * are required fields.
Fields with ** require a numerical value (if zero, leave blank).

About the person who will receive the reimbursement.

(if none, type in "none")

Necessary if you do not have a functional email address.

If you are submitting non-travel expenses incurred in two or more currencies, fill in a form for each currency. We will link the submissions together. If currency is not on the list, choose "Other" & specify in the "Notes" box near the bottom of the form.

If you need to be reimbursed in a currency other than US $, you will need to fill in a Wire Transfer form from the CoDA, Inc. website at:

What budget area is being charged for these expenses.

You may combine multiple receipts that fall into one group.

(or comment about receipt group 1.)

(or comment about receipt group 2.)

(or comment about receipt group 3.)

Sum of boxes a, b, c, & c2
Make sure you carry this total down to box t or u after you review possible adjustments in boxes r, s1, & s2 **

If you would like to donate some of your reimbursement back to CoDA, please enter the amount of your donation here. **


If some or all of the expenses were paid for by CoDA, Inc.'s credit card, enter amount paid on your behalf by CoDA. Attach receipts. **

If d is greater than the sum of r, s1, & s2, enter the amount due member d-(r+s1+s2) **

If the sum of r, s1 & s2 is greater than d, then enter the difference due CoDA, Inc. here. (r+s1+s2)-d

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:
CoDA, Inc.
Fellowship Services Office
P.O. Box 33577
Phoenix, AZ 85067-3577

Upload copies of your receipts here. Policy requires proof of payment for expenses over $30.00 either by receipt or other means of showing payment. All receipts are appreciated under $30.00 to help with record keeping.

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 CoDA, Inc.'s website

(We can do this if you leave the email address in the field below.)
In the next hour you should receive an automated email from Finance Committee sent from This will have an assigned tracking number in the subject line. In the next few days we will forward a separate Confirmation email from SmartSheet to you with the a copy of the information you submitted.

Before you submit this form, you may want to print it to retain all the instructions as well as the information. (This requires a printer or the ability to print to a PDF on your computer.)

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