Employee: _____________________________
For period ending: ______________________
Reimbursement Expense Incurred
Hotels/Lodging $_______________
Meals $_______________
Tax $_______________
Travel (air, train, bus) $_______________
Personal auto (y/n)_____miles x_____ $_______________
Parking $_______________
Phone $_______________
Other (itemize):
__________ $__________
__________ $__________
__________ $__________
__________ $__________ $_______________
Total $_______________
I certify the above is a true statement of incurred expenses in accordance with company policy. Receipts are attached to this statement.
Employee______________________
Approved for payment:
By:___________________________
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