Rev 1/2023
To: Accounts Payable, Finance Dept.
Department Division Period
Hotel Other
B L D
Code For Other Expenses: TOTAL:
A Taxi, Bus or Car Fare
B Telephone
C Parking Fees Mileage: Include mileage summary &/or mapquest printout.
D Train/Plane Fares (attach receipts) Miles @ =
E Registration Fees (attach receipts)
Jul 2022- Dec 2022
Jan 2023- Dec 2023 Miles @ =
F Guest Expenses (Name & Title)
G Miscellaneous (attach receipts) Total Amount of Claim H Tips (program will calculate amounts entered)
I Per Diem
NOTE: Safety shoes, uniform and tools allowance requests - fill out "Reimbursement Form - Payroll (Boots/Uniforms/Tools)" and forward to PAYROLL with original receipt(s) attached. For Wellness and Personal & Professional reimbursements-complete "Personal and Professional Reimbursement Form," attach original receipt(s) and forward to HUMAN RESOURCES. ** Due to IRS regulations, reimbursements for meals for one day (non-overnight) travel are not allowed unless the meal is part of the cost of registration itself or if the meal is for a work meeting.
I have received an advance of $
I certify that this claim is a true record of expenses incurred on official business of the City of south San Francisco during the above period.
Amount of Claim Acct. No. Amount:
Less Advance
$
Acct. No. Amount:
Net Amount Due Acct. No. Amount:
APPROVED BY: Acct. No. Amount:
For Use by the Department of Finance
PRE AUDIT APPROVAL APPROVAL
By: Date:
Director of Finance Date
Date Paid: Check No.
$
$
$
$
Date
$
$
$
$
$
$
$
Date Explanation
Meals ** Daily Total
CITY OF SOUTH SAN FRANCISCO
STATEMENT OF EXPENSE 2023
Administrative Instruction IV.2
Name
0.625
0.655
For employee reimbursements, scan completed form including supervisor signature and attach all receipts & event flyers along with any other supporting documentation to Eden invoice entry.
Classification Employee
, which should be deducted from the above expense.