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Expense Account Statement Form

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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


Approved for payment:


By:_____________________________

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