Gen. Form No.

Revised January 1992

Gen. Form No. 2

REIMBURSEMENT EXPENSE RECEIPT

Date

No.

Revised January 1992

REIMBURSEMENT EXPENSE RECEIPT

Date

RECEIVED from __________________________________________

No.

RECEIVED from __________________________________________

(Name)

(Name)

_____________________________________________ the amount of

_____________________________________________ the amount of

(Official Designation)

(Official Designation)

__________________________________________ (P___________ )
(In Words)

__________________________________________ (P___________ )

(In Figures)

in payment for ____________________________________________

(In Words)

(Payments for subsistence, services,

________________________________________________________

(In Figures)

in payment for ____________________________________________

(Payments for subsistence, services,

________________________________________________________

rental or transportation should show inclusive dates.

rental or transportation should show inclusive dates.

________________________________________________________

________________________________________________________

purposes, distance, inclusive points of travel, etc.)

purposes, distance, inclusive points of travel, etc.)

PAYEE

PAYEE

Name/Signature____________________________________________

Name/Signature____________________________________________

Address__________________________________________________

Address__________________________________________________

Residence Cert. No.________________________________________

Residence Cert. No.________________________________________

Date of Issue______________________________________________

Date of Issue______________________________________________

Place of Issue_____________________________________________

Place of Issue_____________________________________________

WITNESS

WITNESS

Name/Signature____________________________________________

Name/Signature____________________________________________

Address__________________________________________________

Address__________________________________________________

Residence Cert. No.________________________________________

Residence Cert. No.________________________________________

Date of Issue______________________________________________

Date of Issue______________________________________________

Place of Issue_____________________________________________

Place of Issue_____________________________________________

Gen. Form No. 2

Revised January 1992

Gen. Form No. 2

REIMBURSEMENT EXPENSE RECEIPT

Date

No.

Revised January 1992

REIMBURSEMENT EXPENSE RECEIPT

Date

RECEIVED from __________________________________________

No.

RECEIVED from __________________________________________

(Name)

(Name)

_____________________________________________ the amount of

(Official Designation)

(Official Designation)

__________________________________________ (P___________ )
(In Words)

_____________________________________________ the amount of

(In Figures)

in payment for ____________________________________________

(Payments for subsistence, services,

________________________________________________________
rental or transportation should show inclusive dates.

________________________________________________________

__________________________________________ (P___________ )
(In Words)

(In Figures)

in payment for ____________________________________________

(Payments for subsistence, services,

________________________________________________________
rental or transportation should show inclusive dates.

________________________________________________________

purposes, distance, inclusive points of travel, etc.)

purposes, distance, inclusive points of travel, etc.)

PAYEE

PAYEE

Name/Signature____________________________________________

Name/Signature____________________________________________

Address__________________________________________________

Address__________________________________________________

Residence Cert. No.________________________________________

Residence Cert. No.________________________________________

Date of Issue______________________________________________

Date of Issue______________________________________________

Place of Issue_____________________________________________

Place of Issue_____________________________________________

WITNESS

WITNESS

Name/Signature____________________________________________

Name/Signature____________________________________________

Address__________________________________________________

Address__________________________________________________

Residence Cert. No.________________________________________

Residence Cert. No.________________________________________

Date of Issue______________________________________________

Date of Issue______________________________________________

Place of Issue_____________________________________________

Place of Issue_____________________________________________