"Miscellaneous Statement in Lieu of Receipts Template"

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MISCELLANEOUS STATEMENT IN LIEU OF RECEIPTS
Last Name____________ First Name ___________ Middle Initial ____
Rank______
SSN__________________
I hereby certify that the expense(s) claimed below was/were
actually incurred and that the receipt was (check one):
__ impractical to obtain
__ inadvertently lost or destroyed
I further certify that the amount claimed includes only that
expense (i.e. plane ticket, rental car, etc.) and no other. I
understand that the information furnished may be investigated
for validity.
1. Type of receipt (check one):
__ Air Fare
__ Bus Fare
__ Rental Car
__ Limo/Shuttle/Taxi
__ Registration/Conference Fee
__ Other ________________________________
2. Name of business:_____________________
3. Inclusive date(s) of expense: from __________ to __________
4. Amount claimed:____________
5. If for transportation:
point of departure _________________ arrival ___________________
Member's Signature _____________________________
Date _________
MISCELLANEOUS STATEMENT IN LIEU OF RECEIPTS
Last Name____________ First Name ___________ Middle Initial ____
Rank______
SSN__________________
I hereby certify that the expense(s) claimed below was/were
actually incurred and that the receipt was (check one):
__ impractical to obtain
__ inadvertently lost or destroyed
I further certify that the amount claimed includes only that
expense (i.e. plane ticket, rental car, etc.) and no other. I
understand that the information furnished may be investigated
for validity.
1. Type of receipt (check one):
__ Air Fare
__ Bus Fare
__ Rental Car
__ Limo/Shuttle/Taxi
__ Registration/Conference Fee
__ Other ________________________________
2. Name of business:_____________________
3. Inclusive date(s) of expense: from __________ to __________
4. Amount claimed:____________
5. If for transportation:
point of departure _________________ arrival ___________________
Member's Signature _____________________________
Date _________