For students who need to be reimbursed for expenses they’ve incurred while at the School of Applied Intelligence and Finance (SAIF), there is a simple and straightforward process. The SAIF Reimbursement Request Form allows you to submit all necessary documents in one convenient place. It’s especially useful if you need to be reimbursed quickly or if your reimbursement is coming from multiple sources. This blog post will look at how to fill out the form, why it exists, and what needs to happen once it’s completed. Read on for more information about successful submittal of the SAIF Reimbursement Request Form!
| Question | Answer |
|---|---|
| Form Name | Saif Reimbursement Request Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Jan, Washington, 2011, saif reimbursement of expenses form |
Request for Reimbursement of Expenses
Complete form, including claim number, and send to SAIF Corporation. Itemized receipts for each item must accompany this completed form. For prescription medication, please include the pharmacy slip with the name of the physician, medication, date filled, and amount paid, rather than the cash register receipt. Incomplete requests will be returned for additional information. Reimbursement must be requested within 2 (two) years from date of service.
400 High St. SE, Salem, OR 97312 1.800.285.8525
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TRANSPORTATION |
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Start Location |
End Location |
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Trip Miles Date $ Amount |
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TOTAL Transportation
Reimbursement
MEALS
Date $ Breakfast |
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Date |
$ Lunch |
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Date |
$ Dinner |
City |
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TOTAL Meals
Reimbursement
LODGING
Hotel/Motel Name |
Location |
Date |
$ Cost |
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TOTAL Lodging
Reimbursement
PRESCRIPTIONS
Name of Medication |
Doctor |
Date |
$ Cost |
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TOTAL Prescription
Reimbursement
As attested to by my signature and under penalty of law, I certify that all information I have given in this request for reimbursement is true and contains no false statements and/or misrepresentation.
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GRAND TOTAL
Reimbursement
Signature of worker: |
Date: |
F3056 C+D, 4/17/12 |
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Meals and lodging will be reimbursed if you are required to travel a distance for medical treatment that would prohibit you from returning to your local area within a reasonable time frame. An example would be travel in excess of 75 miles each way for meals or a required overnight stay for lodging and meals.
Standard rates for the continental United States:
Lodging and meal rates |
ALL Private Vehicle Mileage effective |
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effective Oct. 1, 2011 |
April 17, 2012 = 55.5 cents per mile |
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Breakfast |
$11.50 |
Previous mileage rates: |
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Lunch |
$11.50 |
01/01/11 = 51.0 cents per mile |
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Dinner |
$23.00 |
01/01/10 = 50.0 cents per mile |
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Lodging |
$77.00 |
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Room tax is reimbursable in addition to the lodging allowance.
Per day rates exceed the standard rate
in the following Oregon locations:
County/City |
Effective |
Max. lodging rate |
Meal rate* |
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Clackamas |
All year |
$88 |
$61 |
Clatsop |
10/1 – 6/30 |
$96 |
$51 |
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7/1 – 8/31 |
$131 |
$51 |
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9/1 – 9/30 |
$96 |
$51 |
Deschutes |
10/1 – 6/30 |
$89 |
$61 |
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7/1 – 8/31 |
$114 |
$61 |
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9/1 – 9/30 |
$89 |
$61 |
Jackson/Klamath |
All year |
$82 |
$56 |
Lane |
All year |
$97 |
$51 |
Lincoln |
10/1 – 6/30 |
$84 |
$56 |
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7/1 – 8/31 |
$105 |
$56 |
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9/1 – 9/30 |
$84 |
$56 |
Multnomah |
All year |
$113 |
$66 |
Washington |
All year |
$93 |
$51 |
*For meals, the following percentages shall be used: breakfast 25%; lunch 25%; dinner 50%