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Member Check Voucher Request
Checks take up to two weeks to process. Please submit promptly to ensure timely reimbursement.
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Name
*
First
Last
Email
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
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District of Columbia
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State
Zip Code
Chapter/Hospital/Clinic
*
Date Submitted
*
I am a/an...
Member organizer
Member political organizer
Executive board member
Executive board members are reimbursed their full rate only if they attend the entire meeting. Late arrivals and early departures will be deducted from your actual hours in 15 minute increments.
Organizer Name
*
Check Request
I am submitting a request for reimbursement for:
*
Mileage
Parking
Wages
Other
Review our
Member Expense Policy
here.
Mileage
Record any mileage over 20 miles.
Date Range
From
Date Range - To
To
Description of trip
Start odometer
End odometer
Miles traveled
Business miles
Miles traveled minus 20 = Business miles
Miles reimbursement
Business miles X $0.70
Parking
Parking Date Range
From
Parking Date Range - To
To
Parking Total
Attach Receipts
Drag & Drop Files,
Choose Files to Upload
You can upload up to 5 files.
Wages
Event
Executive Board
Other
Event Name
Executive Board Session Attended
Jan. 7 2026 – Committee of the Future Meeting
Jan. 14 2026 - Chapter Day and CoF Zoom Cal
Feb. 10-11 2026 - Executive Board Meeting and Lobby Day
Mar. 18 2026 - Committee of the Future Meeting
April 16 2026 - Chapter Day and COF Zoom Call
May 13-14 2026 - Executive Board Meeting
June 16 2026 - Committee of the Future Meeting
July 16 2026 - Chapter Day and COF Zoom Call
Sep. 15-16 - Executive Board Meeting
Oct. 15 2026 - Chapter Day and CoF Zoom Call
Oct. 27 2026 – Committee of the Future Meeting
Nov. 12 2026 - Executive Board Meeting
Dec. 4-5 - Delegate Leadership Assembly
Event Date(s)
From
Event Date(s) - To
To
Shift Hours
8 hours
10 hours
12 hours
Other:
Hours
Total Hours
Add up the total hours you are requesting reimbursement for to cover lost wages.
Hourly Rate
Would you receive premium pay for this shift? If so, list it below.
(Night, evening, lead, preceptor, etc.)
Wages Total
Paystub
SEIU Healthcare 1199NW has my current pay stub on file
SEIU Healthcare 1199NW has I-9 and W-4 on file
If not on file, upload pay rate documents
Drag & Drop Files,
Choose Files to Upload
You can upload up to 2 files.
Other
Date
Item
Other Total
Attach Receipts
Drag & Drop Files,
Choose Files to Upload
You can upload up to 5 files.
Grand Total
Add total amounts highlighted in yellow
Grand Total
With my signature, I am confirming that I am not being paid by my employer in wages, vacation, or any other manner for the time that I have requested wages. I acknowledge that the hours entered are an accurate reflection of my attendance at the event listed above.
Member Signature
Clear Signature
Message
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