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：_____________________________