Employee: 
For period ending: 

REIMBURSABLE EXPENSES INCURRED 

Hotel/Lodging $
Meals $
Tax $
Travel [air, train, bus] $
Personal auto: ____ miles x ___ cents/mile = $
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:

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