"Expense Report Form"
Make check payable to: Routing :Sales & Mkt Mgr Send to: Chief Bus Ofc Accounting Sr, Controller TRAVELER: 2012 E-REGULATION CONFERENCE EXPENSE REPORT Date TOTAL Travel Destination Kansas City, MO Purpose of Trip NAIC E-Regulation Conference Ground Mileage Transportation Miles X $0.555 Parking Taxi/Subway/Rail Airfare Airfare Airfare Booking Fee Airfare Baggage Fee Airfare Change Fee Hotel Room Charge Tips/Baggage Meals Breakfast Provided at the conference Lunch Provided at the conference Dinner Daily Totals I certify that these travel expenses were incurred by me in the transaction of authorized NAIC business. Total Expenses ACCOUNTING DISTRIBUTION Account Department Amount Less Charges pd by NAIC Regulator's Signature Date 59010-45 (from back) 59010-83 Amount Due Commissioner's Signature Date IPSD Director/NIPR Executive Director Date Vendor Number Sr. Controller Date Accounting Review by and date _______________ Voucher Number Page 1 of 4 Page 2 of 4 Page 3 of 4 This form should be completed and forwarded with all receipts to: Terri Hiebert at 1100 Walnut, Suite 1500, Kansas City, Missouri 64106-2197 within 10 days of the conference. Sr, Controller EXPENSES BILLED/CHARGED DIRECTLY TO NAIC P Business Expenses A Date Description Amount I D D I R E C T L Y B Subtotal Y Personal Expenses T Date Description Amount H E N A I Subtotal C Total Charged to NAIC Comments - g:/acctg/data/forms/expense reports/E-Reg Exp Rept.xls Revised 1/07 Page 4 of 4