CONTRACTOR REIMBURSEMENT REVIEW
Tax year:
Payer:
Recipient internal key:
Contract and invoice references:
Payment reference/channel/date:
Total paid:

COMPONENTS
Service fee:
Incidental materials:
Travel allowance:
Actual-cost reimbursement claimed:
Advance paid:
Excess returned and date:
Other:

FACTS
Who contracted with the supplier?
Whose name appears on the receipt?
What accounting did the contractor provide?
What does the agreement require?
Does a repayment relate to an earlier reporting year?
Missing evidence:

DECISION BY COMPONENT
Component | included amount | excluded amount | unresolved amount | reason/source | reviewer/date

[ ] Components equal the payment total.
[ ] No exclusion rests only on an invoice label.
[ ] Advance/repayment counted once.
[ ] Payment-channel review completed.
[ ] Final decision returned to annual recipient rollup.