Expense Reimbursement Request - Nebraska Department …
|Name: |Employee NIS No.: |State of Nebraska |Originating O.E.: | |DOR Document No.: |
| |N/A |Department of Roads |430 | | |
| | |Expense | | | |
| | |Reimbursement | | | |
| | |Request | | | |
|Address: | | | | | |
| | | | | | |
| | | | | | |
| | | |TRANSACTION TYPE | |WARRANT FLAG |
| | | | | |M |R |
| | | |WARRANT WRITING | | | |
|Title: | | | |x | |
| | | | | | |
| | | | | |
|Headquarters: |NDOR Vehicle License No.: | | | | |
| |N/A | | | | |
| | | | | | |
|Date |PARTICULARS |TRAVEL TIME |MEALS |LODGING |PERSONAL VEHICLE USAGE |MISCELLANEOUS |TOTAL |
| | | |(Actual | | | | |
| | | |Amts. Only) | | | | |
| |NAME OF PLACE AND NATURE OF SERVICE | | | |
|DB: 3 | | | |District/Division Approval: |Date: |
| | | | | | |
|DB: 4 | | | | | |
|I claim reimbursement from the State of Nebraska for the above expenses incurred by me in the line of duty and declare that the above statement of |Signature: Employee Other |Date: |
|them is a true account of such expenses for which payment has not been made heretofore by the State of Nebraska. | | |
DR Form 117, March 2007 Distribution: D.A.S./Controller – District/Division - Employee
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Mo/Da/Yr
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