Respondent Expense Report

* Indicates required Field Information

First Name 

Last Name 

Address 

Respondent Email 

Respondent Phone Number 

Purpose of Expense 

Production Title 

Production Institution 

Date Seen 

Total Round Trip Mileage 

Total Round Trip Mileage x.33 

Other expenses (tolls, airfare, parking etc,) 

Meals/Food not covered by Institution 

Description of miscellaneous expenses, if any  

Miscellaneous expenses total 

Total Reimbursement Due 

Date Form Submitted 

You must submit your Mapquest mileage sheets to Stefanie Sertich in order to be reimbursed. You can scan them and send them by email to stefaniekcactf@gmail.com or you can mail the hard copies to:

c/o Stefanie Sertich
KCACTF
35-51 85th St. Apt 1B
Jackson Heights, NY 11372