EXPENSE ACCOUNT STATEMENT

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 Signature



Approved for payment:


By:_____________________________