EXPENSE ACCOUNT STATEMENT

Employee：_________________________________________________________

　　For period ending：________________________________________________

　　REIMBURSABLE¹ EXPENSES INCURRED²

　　Hotel/Lodging $_________________________

　　Meals $_________________________

　　Tax $_________________________

　　Travel [air， train， bus] $_________________________

　　Personal auto³ _____ miles x ___ cents $_________________________

　　Parking $_________________________

　　Phone $_________________________

　　Other [itemize]：

　　_____________________ $_________________________

　　_____________________ $_________________________

　　_____________________ $_________________________

　　_____________________ $_________________________

　　Total： $_________________________

　　I certify⁴ the above is a true statement of incurred expenses in accordance with company policy.  Receipts are attached.

　　_______________________________ Employee

　　Approved for payment：

　　By：_____________________________