Expense Reimbursement Form

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Expense Reimbursement Form Powered By Docstoc
					                            Expense Reimbursement Form

         Send completed form with receipts to the District Governor for approval.
__________________________________________________________________________________________

Name: _______________________________         Position: __________________________________

Address: _________________________________________________________________________


Purpose: _____________________________        Date of Activity: ___________________________

       Transportation – Air/Train, etc. ……………………………                   $ ______

       Automobile Mileage _______ @ $.315 per mile…..……….             $ ______

       Thruway and Bridge Tolls…………………………………                          $_______

       Hotel………………………………………………………….                                   $_______

       Meals………………………………………………………….                                   $_______

       Postage………………………………………………………..                                 $_______

       Telephone……………………………………………………..                                $_______

       Printing………………………………………………………... $_______

       Other ___________________________...…………………….. $_______

              ___________________________...…………………….. $_______

                                              Total                   $_______

Signature: _____________________________________                      Date: __________________

Approved By: ________________________, Governor                       Date: __________________

                                  For District Treasurer’s Use Only

Check Number: ______________          Total Amount: $___________      Date Paid: _____________
District Fund: ________________       Budget Line:   ___________      Amount: $ _____________
District Fund: ________________       Budget Line:   ___________      Amount: $ _____________
District Fund: ________________       Budget Line:   ___________      Amount: $ _____________

				
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posted:9/15/2012
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