REQUEST FOR REIMBURSEMENT OF EXPENSES                       Form # FTR-02


Name:

 

Employee no.:

 

Employee Signature:

 

Address:

 

 

 

Department:

 

Date:

 

Period Covered:

 

To

 

Authorized Signature:

 

Date

Description/Purpose

 Meal Per Diem

Full Day Per Diem

Expenses Actual

 

Account Code Distribution

B

L

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Totals

 

 

 

 

 

  

 

 Meals

 

B

$ 10.00 =

 

 

L

$ 10.00 =

 

 

D

$ 20.00 =

 

 

 

Total Meals =

 

Per diem

  

$ 40.00 =

$

Expenses:

Actual Expenses =

 

 

Total Expenses =

 

 

Less Travel Advance =

 

 

Total Reimbursement =

 

 

 

 

Original receipts MUST be attached