Employee: _
For period ending: _

REIMBURSABLE EXPENSES INCURRED

Hotel/Lodging $_
Meals $_
Tax $_
Travel (air, train, bus) $_
Personal auto _ miles x _ cents $_
Parking $_
Phone $_
Other (itemize):
_ $_

Total: $_
————————-

I certify the above is a true statement of incurred
expenses in accordance with company policy. Receipts are
attached.

_______________________________
Employee

Approved for payment:

By:_____________________________