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:_____________________________