LOST-TIME REIMBURSEMENT FORM

AFSCME LOCAL 3937

Name:             ____________________________________________________________

Address:            ____________________________________________________________

                        ____________________________________________________________

Only starred columns (*) are required—Council 5 will fill in other information.

Date*

Reason for function (be specific)*

Hours*

Hourly rate

 (if known)

Shift diff *

(if applicable)

Amount
           
           
           
           
           
           
           
           

Signature (required for payment)             ____________________________________________________________

Approved by            ______________________________________________________________________________

AFSCME Local 3937

1313 5th St SE Suite 332B

Minneapolis, MN  55414

612-379-3933