2026 APTA Home Health Reimbursement Form.xlsx

	A	B	C	D	E	F	G	H	I
1	APTA HOME HEALTH
2	140B Purcellville Gateway Drive, Suite 120, Purcellville, VA 20132 Suite 120 Purcellville, VA 20132
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4	TRAVEL EXPENSE REIMBURSEMENT REQUEST
5	NAME (PRINT):						XMEMBER ☐NON-MEMBER ☐STAFF
6	STREET ADDRESS:
7	CITY/STATE/ZIP:
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9	TRAVEL PURPOSE:
10		From:	2/11/2026		To:	2/14/2026	To:
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12	See Guidelines for reimbursement limits; original receipts must be attached.
13	TRAVEL EXPENSES
14	DATE								TOTAL
15	CAR MILEAGE ( INSERT MILES)								TOTAL
16	IRS RATE PER MILE (0.725):			$ -	$ -	$ -	$ -	$ -	$ -
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30						TOTAL REIMBURSEMENT
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34	**MISCELLANEOUS EXPENSE RECORD EXPLANATION
35	DATE	NAME OF GUEST (S)			PURPOSE			LOCATION	AMOUNT
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40	è	TRAVELLER: I CERTIFY THIS STATEMENT IS TRUE:
41	è	EXECUTIVE DIRECTOR APPROVED:
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43	FOR STAFF USE ONLY			Travel	Per Diem	Honorarium	Other
44	PROGRAM/PROJECT #
45	ACTIVITY #
46	LINE ITEM
47	FOR ACCOUNTING USE ONLY
48	CHARGE TO:						DATE PAID:
49							CHECK NO:
50							CHECK PROCESSOR:
51							DOC #:
52							DESCRIPTION:
53	FINANCE APPROVAL:
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