Travel+Expense+Claim+Form

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					                         NORTH STATE COOPERATIVE LIBRARY SYSTEM
                                            TRAVEL EXPENSE CLAIM

Use Private Car Mileage Expense Claim for routine local travel. Submit this form immediately following each trip
to: NSCLS Headquarters 55 E St. Santa Rosa, CA 95404-4728 . Detail all expenses on Page 2 of this form.
Receipts must be attached for all expenses exceeding $10.00.



Name:                                                          Position:

Home Address:

Claim Description & Dates:

Destination(s):

Claim Summary: (Please provide detail on Page 2 of this form.)
                                         Personal Expense                  Cal Card Expense            Receipt
Private Car Expense Total:
Airfare or other major transportation:

Car Rental, Taxi:
Meals:
Hotel:
Tips:
Other:


              Sub-total:                      $0.00                             $0.00
         Less cash advance:
        Less other deductibles:

TOTAL CAL CARD EXPENSE:                                                         $0.00
            For Cal Card Expense, please make check payable to: US Bank

         TOTAL CLAIMED:                       $0.00

Charge to:                                            Other:


READ AND SIGN: I request reimbursement for conference and travel expenses detailed herein, which I
incurred in conjunction with my duties with North State Cooperative Library System; and that said expenses, to
the best of my knowledge, are true and correct.

Claimant's Signature:                                                                   Date:




NSCLS OFFICE USE ONLY:                                          Expenditure Code:

           Approved by Supervisor:                                                      Date:

         Approved by Administrator:                                                     Date:


                                                          Page 1 of 2
                                  TRANSPORTATION AND OTHER EXPENSE DETAIL
                                            Transport
Date               From/At          To       Charges         Meal No.           Meals $       Hotel       Other*




 TOTALS:                                           $0.00                0             $0.00       $0.00        $0.00

*Explain:



                                 MILEAGE EXPENSE DETAIL
                                              Trip                              Parking
Date               From/At          To       Mileage         Purpose            & Tolls




 TOTALS:                                                0                             $0.00

            Mileage Allowance:            miles @ 55 cents/mile             $             -

                                                Parking and Bridge Tolls: $               -

                                                                  TOTAL: $                -

    Page 2 of 2                                                                                                        Updated 1/2005

				
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