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 |

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|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 |

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| |_ hari |X |Elaun Makan sebanyak |RM______ /hari |RM_________________ |

| | _ hari |X |Elaun Harian |________/hari |RM__________________ |

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|Jumlah: |RM__________________ |

|TUNTUTAN BAYARAN SEWA HOTEL (BSH)/ELAUN LOJING |

| |__ hari |x |BSH sebanyak |RM____________/hari |RM_____________ |

| |[Resit :___________________________________________________________ ] | |

| |Bayaran Perkhidmatan dan Cukai Kerajaan: | |RM_____ ______ |

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| |_ 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) |

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| |Nama : |

| |Tarikh : |

|PENGESAHAN |

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| |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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