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Mileage Expense Claim - DOC by 649v7x0E

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									       HABEMATOLEL POMO OF UPPER LAKE
                           Mileage Expense Claim
 Name of Claimant: __________________________ Position: ____________________

 Date of Claim: ___________ Car License Plate: ____________ Program: __________

 Approval: _____________________________      ______________________________
           Supervisor           Date          Tribal Administrator    Date

           _____________________________      ______________________________
           Fiscal Office        Date          Tribal Chairperson      Date


         Time    From/      Odometer          Odometer
Date    In\Out   Out     Reading Leaving       Reading           Miles     Purpose of Trip
                                              Returning




                                              Total Miles Page 1: _____
 _____________________________________        Total Miles Page 2: _____
 Traveler’s Signature          Date           Total Miles Claimed: ______ x $0.585 = _______
                                              Other (toll/parking): ______
                                              Total Amount of Claim: _______


FISCAL USE ONLY

Vender: _____________________________       Check # _______________
                                                          Form revised as of 7/31/2012

								
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