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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