(Complete and return to Troop Treasurer)

Complete as appropriate:

___ No. of scouts transported

___ No. of seatbelts available

___ Gear only

___ Trailer

Driver's Name: ___________________________________

Campout Date: ___________________________________

Actual gas cost + _______

Parking fee* or toll* (if any) + _______

Payment by passengers - _______

Total allowable reimbursement = _______

I wish to claim $ _______________ for this campout.

Payment made by __________________________________________

Date ___________________

Amount: _____________ Method of payment: ___________________

Payment received by ________________________________________

Date ____________________

*You must use all available seatbelts (3 Scout minimum, if possible) or transport a load of equipment for full reimbursement; if less, it should be prorated.