Request for Reimbursement of Rescue Expense

Please complete the form below to request reimbursement for your Rescue expenses.

Date*

Dog's Name*

Your Name*

Your Email*

Address*

City, State, ZIP*

Phone*

EXPENSES ($300 limit unless otherwise approved by the Rescue Committee)

To Obtain Dog - Total Miles

Total @ $.14 per mile: $

To Place Dog - Total Miles

Total @ $.14 per mile: $

Veterinary (Explain)

Total Veterinary: $

Upload File (itemize and attach all documentation for Veterinary services):

Boarding Facility Name

Number of Days

Price Per Day

Boarding Total (Must be approved by Rescue Committee)

Boarding Total: $

Grooming ($50.00 allowable grooming charges)

Grooming Total: $

Upload File (please itemize and attach documentation):

Other Description:

Other Total: $

Upload File (please itemize and attach documentation):

TOTAL EXPENSES TO BE REIMBURSED*

GRAND TOTAL: $

Please specify how we should process these expenses*: I want to be reimbursed.I am donating these expenses.