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Expense Claim for (Name)
____________________________ |
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Street
Address________________________________ |
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City
_______________________ WA Zip
_____________ |
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Activity: Developing
a Student Skill Ladder |
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Travel Expenses: To
________________________________________ |
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Roundtrip mileage |
Miles |
x |
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Date: ____
/ ____ / 200__ |
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x |
$0.31 |
= |
$ |
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____ / ____ / 200__ |
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x |
$0.31 |
= |
$ |
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Subtotal 1 (S1) |
$ |
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Lodging |
Hotel Room |
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Date: ____
/ ____ / 200__ |
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= |
$ |
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____ / ____ / 200__ |
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= |
$ |
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____ / ____ / 200__ |
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$ |
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____ / ____ / 200__ |
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$ |
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Subtotal 2 (S2) |
$ |
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Public Transit Fees with
receipts |
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Date: ____
/ ____ / 200__ |
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= |
$ |
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____ / ____ / 200__ |
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= |
$ |
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Subtotal 3 (S3) |
$ |
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Breakfast max. $10 |
Lunch max. $15 |
Dinner max. $20 |
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Meals with receipts |
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Date: ____
/ ____ / 200__ |
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= |
$ |
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____ / ____ / 200__ |
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= |
$ |
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____ / ____ / 200__ |
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= |
$ |
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____ / ____ / 200__ |
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Subtotal 4 (S4) |
$ |
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Charge off to : 79-95-27-800-15-06 |
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Total S1+ S2+S3+S4 |
$ |
T1 |
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Stipend for: |
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Activity____________________ |
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$ |
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Activity____________________ |
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$ |
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Activity____________________ |
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$ |
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Charge off to : 79-95-27-700-15-06 |
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Total |
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T2 |
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Other Expenses |
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Other Expenses with
receipts; please note any expense greater than $25 should be approved by
David Tucker prior to purchase. |
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Item _____________________ |
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$ |
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Item _____________________ |
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$ |
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Item _____________________ |
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$ |
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Charge off to : 79-95-27-500-15-06 |
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T3 |
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Grand Total Reimbursement T1+T2+T3 |
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Employee Signature___________________________________________ __/__/200_ |
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Budget Director
Signature______________________________________ __/__/200_ |
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Budget Manager
Signature______________________________________ __/__/200_ |
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Complete the top section
fully. All requests must be approved by the Budget Director and Project
Director. |
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Mail this form to: Ken
Bakken, PO Box 95, Deming, WA 98244. |
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Copy your receipts for your
records; originals must be submitted with this form for reimbursement. |
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Deadline for form
submission is the last Friday of each month in order to receive payment the
next month. |
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