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Revised January 1992

REIMBURSEMENT EXPENSE RECEIPT


Date

No.
Received from
the amount of
(Official Designation)
(P____________________)
(In Figure)

(In words)
In payment for _____

Payments for subsistence service


Rental or Transportation should show inclusive date
Purpose, distance, inclusive points of travel, etc.

PAYEE
Name/ Signature:
Address:
Res. Cer. No. _____________________Date Issue:

Place Issue:

WITNESS
Name/ Signature:
Address:
Res. Cer. No. _____________________Date Issue:

Place Issue:

_____)
re)

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