KULM PUBLIC SCHOOL DISTRICT #7, PO BOX G, …



DATE: ____________________ PAYABLE TO: __________________________________

ADDRESS: __________________________________

ODOMETER READING:

Paid per Diem according to State Reimbursement __________________________________

(Kulm School pays $.58 per mile)

__________________________________

NAME OF PLACE/CITY TRAVELED TO: __________________________________________________

FROM______________ TO______________ = TOTAL MILES ______________________________________

(odometer reading)

FROM______________ TO______________ = TOTAL MILES ______________________________________

(odometer reading)

FROM______________ TO______________ = TOTAL HOURS _____________________________________________

(time/hour) (time/hour) (pertains only to employees paid an hourly salary)

PURPOSE/REASON FOR REIMBURSEMENT: ______________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Meals will be paid as per Diem according to State Reimbursement.

Payment will be made accordingly but will not exceed meal allowance listed below.

MEALS:

BREAKFAST: ($7.50) ____________ In order to claim breakfast, you must leave before 7 a.m.

LUNCH: ($10.00) ____________

DINNER: ($17.50) ____________ In order to claim dinner, you must return after 7 p.m.

EXPENSES:

MILEAGE: $___________________________

_______________________________

(Payment Requested By) HOURS: $______________________________

_______________________________ MEALS:$ ______________________________

(Approved By Superintendent)

OTHER:$ ______________________________

_______________________________

(Date Approved) TOTAL EXPENSES:$ _____________________

FUND/ACTIVITY GROUP & CODE TO BE PAYABLE FROM:

FUND____________GROUP____________________CODE_________________________________________________________

FUND____________GROUP____________________CODE_________________________________________________________

FUND____________GROUP____________________CODE_________________________________________________________

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