EXPENSE ACCOUNT STATEMENT FORM Employee:_________________________________________________________ For period ending:________________________________________________ REIMBURSABLE EXPENSES INCURRED Hotel/Lodging $_________________________ Meals $_________________________ Tax $_________________________ Travel (air, train, bus) $_________________________ Personal auto _____ miles x ___ cents $_________________________ Parking $_________________________ Phone $_________________________ Other (itemize): _____________________ $_________________________ _____________________ $_________________________ _____________________ $_________________________ _____________________ $_________________________ Total: $_________________________ -------------------------I certify the above is a true statement of incurred expenses in accordance with company policy. Receipts are attached. _______________________________ Employee Approved for payment: By:_____________________________