COBRAS Expense Form

Instructions:

• If you are to be reimbursed, please be sure your email and address information on the form is correct. Normally, reimbursements are made via a bank bill pay check and will be mailed to the address listed on this form.
• For each item, please indicate the vendor, expense category and the amount.
• Please scan or photograph the receipt and upload the file to the form.
• If the expense is for items in multiple categories, enter a line for each category.
• Any sales tax should be prorated into each category.
• If you are not sure of the category, or the category is not listed, select “other” and write an explanation in the comments section of the form.
• If you used a COBRAS check, enter the check number.

Thank you.

Note: The fields below will scroll left and right.

Member Name:
Member Email:
Member Address:	MEMSTREET MEMCITY MEMSTATE MEMZIP
Date:

Item 1:	Vendor: Catagory: Select Category:[php function=11] Check# Amount: Receipt:
Item 2:	Vendor: Catagory: Select Category:[php function=11] Check# Amount: Receipt:
Item 3:	Vendor: Catagory: Select Category:[php function=11] Check# Amount: Receipt:
Item 4:	Vendor: Catagory: Select Category:[php function=11] Check# Amount: Receipt:
Comments:
How Paid:	Paid via COBRAS PayPal Paid via COBRAS Check Paid via COBRAS Debit Card Reimburse Me Please

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