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APPROVAL SIGNATURE
CLAIMANT SIGNATURE
DATE
TITLE
DATE APPROVED
TITLE
OFFICIAL DOMICILE
STATE OF MISSOURI
MONTHLY EXPENSE REPORT
MO 300-0966 (4-06)
DISTRIBUTION: WHITE/OA ACCTG.
CANARY/AGENCY
PINK/EMPLOYEE RETAINED
SAM II
FOR MONTH OF
PAGE
OF
THE WHITE AREAS MUST BE COMPLETED. THE GRAY AREAS ARE OPTIONAL
FOR AGENCY USE. SEE INSTRUCTIONS ON BACK.
DEPARTMENT/DIVISION OR INSTITUTION
EMPLOYEE NAME (LAST, FIRST)
VENDOR CODE (SOCIAL SECURITY NUMBER)
OFFICE ADDRESS
WORK PHONE NO.
UNIT/COUNTY
LOCATION CODE OR DOCUMENT NO.
DATE
FROM/TO & PURPOSE
STANDARD
MILES
FLEET
MILES
BREAK-
FAST
LUNCH
DINNE
LODGING
BUS
R.R.
AIR
MISC.*
TOTAL
TOTALS OF ABOVE
TOTALS FROM OTHER PAGES
TOTAL STANDARD MILES
TOTAL FLEET MILES
AT
¢ PER MILE
AT
¢ PER MILE
TOTAL REIMBURSABLE EXPENSE
TOTAL INSTATE
TOTAL OUTSTATE
$
$
DATE
* EXPLANATION OF MISCELLANEOUS
I hereby certify the above claim is correct, that these expenses were necessary to conduct state business, that payment has been made from
personal funds for which I have not been reimbursed, nor will I receive from any source any payment for these expenses.
FUND
AGCY
ORG/SUB
APPR UNIT
ACTIVITY
OBJ/SUB
JOB NUMBER
VERIFIED BY AND DATE
CODED BY AND DATE
CK CATEGORY
AMOUNT
.37
.260
Jan 21, 2010