Request for Reimbursement of Expenses F3921 (Formerly F3056), English version 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Name', 'Street address', 'City', 'State', and 'Zip' fields. Ensure all details are accurate to avoid delays.
3. Input your claim number, phone number, and email address in the designated fields. This information is crucial for processing your request.
4. For mileage reimbursement, fill in the travel date, start location, end location, medical purpose, total miles traveled, and the amount you are claiming based on the current mileage rate.
5. If applicable, provide details for pharmacy or other medical expenses by including the date of purchase, name of medication/supplies, prescribing doctor’s name, and amount paid.
6. For meals and lodging claims, list each meal's cost along with lodging expenses. Remember to attach itemized receipts as required.
7. Finally, review all entries for accuracy before signing and dating the form at the bottom. This certification confirms that all provided information is true.

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