STATEMENT OF BOOK EXPENSE
State Form 13734 (R2 / 9-94) / VRS 0008
Name Address (number and street, city, state, ZIP code) Training facility NAME OF BOOK OR SUPPLY PLACE OF PURCHASE Billing date QUANTITY PRICE
TOTAL
$
PLEASE ATTACH SALES SLIPS I certify that I am in training and that I am entitiled to this compensation as per the terms of written authorization for such services.
Signature Date
Signature of Counselor
Date