Project Title:

Student:

Address:

Social Security #:                                                                    Date:

Faculty Mentor:

ALLOWABLE EXPENSES:
(Attach "ITEMIZED EXPENSE LIST" and receipts to this form)

TRAVEL

In-State ($.345 per mile for the first 500 miles; $.17 per mile for 501 to 3000 miles)
Note: All mileage is counted from the IUSB campus to your destination

Out-of-state:

LODGING (submit original receipts only)

SUPPLIES (Must be specifically project-related and itemized with original receipts attached. This includes all duplicating costs.)

OTHER

TOTAL REIMBURSEMENT REQUESTED:

I verify that these were the actual expenses for my Undergraduate Research Project. I have also submitted my finished project, Self‑Evaluation, Travel Report (if any). I authorize the Undergraduate Research Office to sign for me all necessary university reimbursement request forms.

Signature of Student Applicant:

Signature of Faculty Mentor: