GRH Reimbursement Form

Name

CATMA User Name

Found on your user profile here: https://catma.agilemile.com/profile.php?t=account

Email Address

Telephone Number

REIMBURSEMENT REQUEST DETAILS

Date & Time of GRH Request

Vendor Name

Pick-Up Location

Please provide address

Drop-off Location

Please provide address

Reason for GRH

Receipt

Max. file size: 2 MB.

Please upload an image of the trip receipt (gif, jpg, png). Files must be less than 2 MB. Allowed file types: gif jpg jpeg png.

Reimbursement Verification

I attest all information provided is correct

I understand the maximum amount for a reimbursed trip is $70 (tips are not reimbursable)

By selecting the boxes below you are verifying this trip was taken by you and utilized under the program guidelines