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This accounting is an accurate statement of my actual disbursements, b. the. Claim for Reimbursement for Expenditures on Official Business.The PERSONAL REIMBURSEMENT REQUEST form is 1 page long and contains: 0 signatures; 0 check-boxes; 54 other fields. Country of origin: OTHERS File type: PDF. Side of this form for reimbursement guidelines and allowable rates. SECTION 1 – Injured employee's information. For personal expense reimbursement, complete and return to WSI the Request for Personal Reimbursement form (C40a). Enter a relevant comment about what this report is for. The request for reimbursements should be summarized on the travel reimbursement form. FSHN PERSONAL REIMBURSEMENT REQUEST - NOT TRAVEL RELATED.