Step 2: Expense Submission

Submit completed form with actual amounts spent and attach receipts and all appropriate forms.

PO# (if applicable)*
The purchase order number that was given to you for this purchase (if applicable, otherwise type n/a).
Type of Purchase*
- Personal Reimbursement
- BLT PCard
- Agent Agency PCard
- Vendor Account
Your Name*
You must complete, sign and submit an AG-296 form along with your receipts if this is a personal reimbursement. Click on this link for the AG-296 form.
Cardholder Name & Number (last 4 digits)*
Concur Allocations*
- Allocations will be completed by Agent responsible.
- Allocations will be completed by district delegate. ♦
♦ You must set up district office manager as your delegate for expense allocation purposes. Click here for instructions on setting up delegate on Concur You will only need to do this once.
Vendor Name*
To whom will this invoice be paid - where was purchase made?
Invoice Number
Date Received*
Date all items were received.
MM slash DD slash YYYY
Account Number*
Paper Goods/Demonstration Supplies (4010)
Please type the Total Cost of items purchased in this category.
Food Purchases used for teaching or demonstration purposes (4050)
Please type the Total Cost of items purchased in this category.
Food Purchases for Refreshments/Food served (6339)
Please type the Total Cost of items purchased in this category.
Other Expenses
Please type the Total Cost of any other items purchased that do not fit in the categories above.
Description / Justification*
Enter a short valid justification for your purchase. Please include event name/date/location if applicable. For all FOOD purchases include who, what, when, why, where with regards to the purchase.
Type your initials here to verify that NO TAXES were charged.*
Email*
Email address of the person submitting this request. A copy of this request will be forwarded to the email provided.
Total
This total should equal the amount of your receipts and be the same amount requested on your AG-296 form if this is for reimbursement.
$0.00
ATTACH BACKUP DOCUMENTATION*
Please upload the invoice, itemized receipts and other forms as appropriate.
ALL DOCUMENTS MUST BE SUBMITTED IN ONE FILE. DO NOT upload files separately.
Max. file size: 20 MB.