Member Check Voucher Request Checks take up to two weeks to process. Please submit promptly to ensure timely reimbursement. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChapter/Hospital/Clinic *Date Submitted *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I am a/an…Member organizerMember political organizerExecutive board memberExecutive 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 RequestI am submitting a request for reimbursement for: *MileageParkingWagesOtherReview our Member Expense Policy here.MileageRecord any mileage over 20 miles. Date RangeDescription of tripStart odometerEnd odometerMiles traveledBusiness milesMiles traveled minus 20 = Business milesMiles reimbursementBusiness miles X $0.56ParkingParking Date RangeParking TotalAttach Receipts Click or drag files to this area to upload. You can upload up to 5 files. WagesEventExecutive BoardOtherEvent NameExecutive Board Session AttendedThursday, January 11, 2024Field day in February 2024Wednesday, March 6, 6024Thursday, April 18, 2024Thursday, May 15, 2024Wednesday, June 12, 2024Tuesday, July 16, 2024Thursday, September 12, 2024Wednesday, October 16, 2024Thursday, November 14Friday, December 6, 2024Saturday, December 6, 2024Event Date(s)Select a range.Shift Hours8 hours10 hours12 hoursOther:HoursTotal HoursAdd up the total hours you are requesting reimbursement for to cover lost wages.Hourly RateWages TotalPaystubSEIU Healthcare 1199NW has my current pay stub on fileSEIU Healthcare 1199NW has I-9 and W-4 on fileOtherDateItemOther TotalAttach Receipts Click or drag files to this area to upload. You can upload up to 5 files. Grand TotalAdd total amounts highlighted in yellowGrand TotalWith 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 SignatureEmailSubmit