Prime Expense Reimbursement Report

Prime Expense Reimbursement Report
Expense Incurred by:*
Advisor Name
Prime Level*
Quarterly Allowance
Quarterly Allowance used to date:
What type of expenses are you reporting?

NOTE: If the expense you are reporting is recurring, please use a separate numbered item for each month.
Required:*

Business Software, Client Resource Material, Business CoachingGNL Mileage
Please select how many business expenses you are submitting
Please select how many GNL Mileage expenses you are submitting
Business Software, Client Resource Material, Business Coaching
Item #1
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #1 here:

Cancelof
Item #2
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #2 here:

Cancelof
Item #3
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #3 here:

Cancelof
Item #4
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #4 here:

Cancelof
Item #5
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #5 here:

Cancelof
Item #6
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #6 here:

Cancelof
Item #7
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #7 here:

Cancelof
Item #8
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #8 here:

Cancelof
Item #9
Date

MonthDayYear
Provide date expense incurred
Purpose
Description
Provide company name and a brief description of the coaching, material, or software
Total ($)
Upload any files applicable to item #9 here:

Cancelof
GNL Mileage
Item #1
Date

MonthDayYear
Provide date expense incurred
Mileage*
Enter Miles
*Mileage will be reimbursed at the current standard IRS mileage rate
Upload any files applicable to item #1 here:

Cancelof
Item #2
Date

MonthDayYear
Provide date expense incurred
Mileage*
Enter Miles
*Mileage will be reimbursed at the current standard IRS mileage rate
Upload any files applicable to item #2 here:

Cancelof
Item #3
Date

MonthDayYear
Provide date expense incurred
Mileage*
Enter Miles
Upload any files applicable to item #3 here:

Cancelof
*Mileage will be reimbursed at the current standard IRS mileage rate
Item #4
Date

MonthDayYear
Provide date expense incurred
Mileage*
Enter Miles
Upload any files applicable to item #3 here:

Cancelof
*Mileage will be reimbursed at the current standard IRS mileage rate
Item #5
Date

MonthDayYear
Provide date expense incurred
Mileage*
Enter Miles
Upload any files applicable to item #3 here:

Cancelof
*Mileage will be reimbursed at the current standard IRS mileage rate
Item #6
Date

MonthDayYear
Provide date expense incurred
Mileage*
Enter Miles
Upload any files applicable to item #3 here:

Cancelof
*Mileage will be reimbursed at the current standard IRS mileage rate
Grand Total
Investment Advisor Name*
Investment Advisor Signature*

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Date*

MonthDayYear
Deliver filled form to:*
example@example.com
Upon clicking submit, a PDF copy of this form will be sent to the Compliance Team at Vicus Capital. A PDF copy of the request will also be provided to the email entered into the "Deliver filled form to:" field.
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