ACCOUNTABLE REIMBURSEMENT PLAN

EXPENSE REPORT SUMMARY FORM

Name:_____________________________ Period Covered:___________ to __________

Ø Local transportation -- ____________miles @ __________¢ =.............. $________________

(see attached Form A for detail)

Ø Parking and tolls............................................................................. $________________

(see attached Form A for detail)

Ø Travel Expenses - away from home overnight, includes meals and lodging.............. $________________

(attach supporting detail)

Ø Business Meals and Entertainment.................................................... $________________

(see attached Form B for detail)

Ø Books, periodicals, etc..................................................................... $________________

(attach receipts)

Ø Office Supplies, etc......................................................................... $________________

(attach receipts)

Ø Continuing Education....................................................................... $________________

(attach receipts and detail)

Ø Long distance telephone.................................................................. $________________

(attach documentation)

Ø Other Miscellaneous........................................................................ $________________

(attach support)

TOTAL REIMBURSABLE EXPENSES........................................... $_______________

Less Advance Received, if any................................................... $(______________)

Net Due.......................................................................... $______________

______________________________________ ______________________________

(Staff Person's Signature) (Date)

_______________________________________ _____________________________

(Approved, Staff Parish Relations Chairperson) (Date)