Name:

Date:

Reason for Expense:

DATE	PLACE	EXPENSE ITEM	LOCAL CURRENCY	EXCHANGE RATE	TOTAL

Expense Claim Number:	TOTAL
Check Number:	LESS ADVANCE
Amount Paid:	AMOUNT DUE CLAIMANT
Claimant Position:	AMOUNT DUE IFALDA

Claimant Signature:

Expenses Approved by V.P. Finance: