LAMPIRAN “A”
LAMPIRAN “A”
KENYATAAN TUNTUTAN ELAUN PERJALANAN DALAM NEGERI
BAGI /
(Bulan) (Tahun)
(SILA LENGKAPKAN DALAM DUA (2) SALINAN)
|MAKLUMAT PEGAWAI |
|Nama |: | |
|(Huruf Besar) | | |
|No. Kad Pengenalan |: | |
|Gred/Kategori/ |: | | |
|[Kumpulan (()] | | |I , II , III , IV , V , VI , VII , VIII , IX , X , XI (Sila bulatkan) |
| |: | |
|Jawatan | | |
|Bank & No. Akaun |: | |
|No. hp / e-mel |: | |
|Pendapatan (RM) |Gaji |: | |
|(Seperti dalam penyata gaji bulan| | | |
|semasa) | | | |
| |Elaun-Elaun |: | |
| |Jumlah |: | |
|Kenderaan |Jenis/Model |: | |
|(Sila lengkapkan ruangan ini | | | |
|sekiranya menuntut tuntutan | | | |
|perbatuan) | | | |
| |No. Pendaftaran |: | |
| |Kuasa (c.c.) |: | |
| |Kelas Tuntutan |: | |
|Alamat Pejabat | |
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|Alamat Rumah | |
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|KENYATAAN TUNTUTAN |
|Tarikh |Waktu |Tujuan/Tempat |Jarak (km) |Tambang |
| |Bertolak |Sampai | | | |
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|TUNTUTAN ELAUN PERJALANAN KENDERAAN |
| |
|Bagi: |
| |500 km pertama | |_______ km |x |_______sen/km: |RM_________________ |
| |150 km selepas |500 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |650 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |800 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |950 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |1,100 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |1,250 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |1,400 km: | km |x |_______ sen/km: |RM_________________ |
| |150 km selepas |1,550 km: | km |x |_______ sen/km: |RM_________________ |
| |Setiap km selepas |1,700 km | km |x |_______ sen/km: |RM_________________ |
|Jumlah: |RM_________________ |
|TUNTUTAN TAMBANG PENGANGKUTAN AWAM |
| |Teksi (**) |[Resit _ _____] |RM____ ____ |
| |Bas (**) |[Resit _ ___________ _____________________ _________] |RM_________________ |
| |Keretapi |[Resit ______________________________ _____________] |RM_________________ |
| |Feri (**) |[Resit ___________________________________ ________] |RM_________________ |
| |Lain-lain |[Resit ] |RM |
|Jumlah: |RM |
|TUNTUTAN ELAUN MAKAN/ELAUN HARIAN |
| | | | | | |
| |_ hari |X |Elaun Makan sebanyak |RM______ /hari |RM_________________ |
| | _ hari |X |Elaun Harian |________/hari |RM__________________ |
| | |
|Jumlah: |RM__________________ |
|TUNTUTAN BAYARAN SEWA HOTEL (BSH)/ELAUN LOJING |
| |__ hari |x |BSH sebanyak |RM____________/hari |RM_____________ |
| |[Resit :___________________________________________________________ ] | |
| |Bayaran Perkhidmatan dan Cukai Kerajaan: | |RM_____ ______ |
| | | | | | |
| |_ hari |X |Elaun Lojing sebanyak |RM /hari |RM |
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| | |
| |Alamat Lojing: |
|Jumlah: |RM __________________ |
|TUNTUTAN PELBAGAI |
| |Yuran Pendaftaran |[Resit __ ___________________] |RM___ _________ |
| |Tempat Letak Kereta |[Resit _________________________________] |RM_________________ |
| |Dobi |[Resit _________________________________] |RM_________________ |
| |Pos |[Resit _________________________________] |RM_________________ |
| |Telefon, Teleks, Faks |[Resit _________________________________] |RM_________________ |
| |Kerugian pertukaran matawang asing (@ 3%) [Bagi Singapura, Selatan Thailand, Kalimantan dan Brunei Darussalam |RM_________________ |
| |sahaja]: | |
| |JUMLAH TUNTUTAN KESELURUHAN: |RM _________________ |
|PENGAKUAN |
| |Saya mengaku bahawa: |
| |(a) |perjalanan pada tarikh-tarikh tersebut adalah benar dan telah dibuat atas urusan rasmi; |
| |(b) |tuntutan ini dibuat mengikut kadar dan syarat seperti yang dinyatakan di bawah peraturan- |
| | |peraturan bagi pegawai bertugas rasmi dan/atau pegawai berkursus yang berkuatkuasa |
| | |semasa; |
| |(c) |perbelanjaan yang bertanda (**) berjumlah sebanyak RM_________ telah sebenarnya dilakukan dan dibayar oleh saya; |
| |(d) |panggilan telefon sebanyak RM___________________ dibuat atas urusan rasmi; dan |
| |(e) |butir-butir seperti yang dinyatakan di atas adalah benar dan saya bertanggungjawab |
| | |terhadapnya. |
| | |
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| |………………………………………. |
| |(Tandatangan Pemohon) |
| | |
| |Nama : |
| |Tarikh : |
|PENGESAHAN |
| | |
| |Adalah disahkan bahawa perjalanan tersebut adalah atas urusan rasmi. |
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| |Tarikh: …………………… | |
| | ……………………………… | |
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| |(Tandatangan) | |
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| |KETUA UNIT/JABATAN |……………………………… |
| | |(Tandatangan) |
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| | |DR DAVIS JOHNRAJ |
| | |Pengarah Hospital, |
| | |Hospital Bintulu |
| | |b.p. Ketua Setiausaha/ |
| | |Pegawai Pengawal |
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|PENDAHULUAN DIRI (jika ada) |
| |Pendahuluan diri diberi |RM_________________ |
| |TOLAK: Tuntutan sekarang |RM_________________ |
| |Baki dituntut/Baki dibayar balik |RM_________________ |
Catatan:
(() - jika pegawai memilih untuk tidak menerima SSB.
((() - jika tidak ada resit bayaran.
Lampiran I
TEMPAT/TUJUAN PERJALANAN TEKSI
|Tarikh |Tempat/Tujuan |Amaun |
| | |(RM) |
| |Dari |Ke | |
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Disahkan betul oleh: ………………………………………….
(Tandatangan Pemohon)
Nama: …………………………………………………………
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