Expense Account Statement Form


Account of :_________________________ (employee name)
From _____________ to ______________

Reimbursable Expenses Incurred

Lodging $_______________________
Meals $_________________________
Travel [air/train/bus/auto] $________________
Personal automobile _____ miles x ___ cents $____________
???????Parking _____ hours x ______ dollars $______

Others (itemize):
________________ $______________
________________ $______________
________________ $______________
________________ $______________
Total: $________________________

Grand Total: $__________________

Select one
[] Credit to account of _____________________
[] Send check to ____________________________

I certify the above is a true statement and that the expenses claimed were incurred by me on official business.? Receipts for each expense are attached.


Approved for payment:


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