university sport south africa claim form 2012

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					                                         UNIVERSITY SPORT
                                           SOUTH AFRICA
                                         CLAIM FORM 2012
 Claimant (Person submitting claim): _____________________________________________________________
 Position in USSA: _____________________________________________________________________________
 Member institution: ___________________________________________________________________________
 Beneficiary (Account name): ____________________________________________________________________
 Bank (Name): ______________________________            Branch code: ___________________________________
 Account type: ______________________________           Account number: ________________________________
 Date(s) of expenses: _________________________         E-mail: ________________________________________
 Reasons for expenses: __________________________________________________________________________

                                DETAILS OF CLAIM                                           AMOUNT
                 (Please add all verifying documents and/or receipts)
 1.     Travel expenses (Refer to policy / Attach summary for multiple trips)
        1.1     Own vehicle ______________ km @ R3.05 p/km                               _______________
        1.2     Car hire                                                                 _______________
        1.3     Petrol                                                                   _______________
        1.4     Parking                                                                  _______________
        1.5     Air ticket(s)                                                            _______________
        1.6     Other public transport                                                   _______________

        Sub-total:                                                                       _______________
 2.     Accommodation (Refer to policy)
        2.1     Day allowance _____ days @ R100.00 per day OR actual hotel costs         _______________
        2.2     Meals / refreshments                                                     _______________
        2.3     Telephone / fax / internet costs                                         _______________

        Sub-total:                                                                       _______________
 3.     Other proven expenditure (Refer to policy / Attach summary)
        3.1     __________________________________________________                       _______________
        3.2     __________________________________________________                       _______________
        3.3     __________________________________________________                       _______________

        Sub-total:                                                                       _______________


        GRAND TOTAL:                                                                     _______________

                                                                                               Date:
 Signature of Claimant: ___________________________________________                      _______________


Payment approved by:


_____________________________________              _______________     ____________________________________
       SECRETARY GENERAL                                DATE                CHAIRPERSON / TREASURER

				
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