ROTARY INTERNATIONAL AND ROTARY FOUNDATION EXPENSE STATEMENT

Name:
Rafiq Ahmed Siddique
Rotarian/Staff/Officer
Rotarian
:
Staff Liaison:

Total Expenses (US$):

Total Advance Amount:

2588663
SIDDIQUES' Apt. # A-1, House # 13, Road
#7
Gulshan-1, Dhaka -1212.
Due to Individual or (Due RI): $

Rotary ID:
Address:

Country:
E-mail:

Bangladesh

Any Spouse Related Expenses

rafiq@bol-online.com

Payment Option:

RI Exchange Rates

Date

24-Nov-16
28-Nov-16
5-Dec-16
24-Nov-16
25-Nov-16
26-Nov-16
27-Nov-16
27-Nov-16
27-Nov-16
28-Nov-16
29-Nov-16
30-Nov-16
1-Dec-16
2-Dec-16
3-Dec-16
4-Dec-16

Expense
Type

Payee Form
Payment Guidelines

Spouse Form
Contribution Form

Description/
Business Purpose of Expense

Others Present
(Business Relationship & Number)

Airfare

Dhaka - Karachi

Airfare

Karachi - Bangkok

Airfare

Bangkok - Dhaka

Lodging

TRF Seminar D3271

Lodging

TRF Seminar D3271

Lodging

TRF Seminar D3271

Lodging

TRF Seminar D3271

Transportation

Return to Karachi Airport

Lodging

GETS 2016 Bangkok

Lodging

GETS 2016 Bangkok

Lodging

GETS 2016 Bangkok

Lodging

GETS 2016 Bangkok

Lodging

RRFS 2016 Bangkok

Lodging

Bangkok Institute 2016

Lodging

Bangkok Institute 2016

Lodging

Bangkok Institute 2016

28-Nov-16

Transportation

Airport to Hotel

28-Nov-16
29-Nov-16
1-Dec-16
3-Dec-16
4-Dec-16

Meals

Room Service

Meals

Lobby Lounge

Meals

Lobby Lounge

Meals

REDSKY

Transportation

Hotel to Airport

5,373.40

For AP Dept Use Only:

Date(s) Cover

Vendor # - Location:

Title/Office:

RRFC, 2014-2017

Location of
Assignment:

Zone 6B

Assignment:

RRFC, 2014-2017

Currency:

5,373.40

Exch Rate:

Signature:
Guidelines for Submitting Expense Statement
Guidelines for Using RI Exchange Rates
Amount of
Expense (in local
currency)

Half day Charge

Availed on 27 Nov, but charged on 28

Nov

Currency

US$
Total

Exchange Rate

540251

23.88
26.23
22.19
206.14
71.43

Not Req
Not Req
Not Req
Required
Not Req

540251
540251
540251
540251
540251

2,400.00

THB

35.00000000

835.67
918.06
776.82
7,215.01
2,500.00

THB
THB
THB
THB
THB

35.00000000
35.00000000
35.00000000
35.00000000

Director/Staff Contact
Approval:

* Date:

For RI Staff Use Only

Cost Ctr - Prod
Code

Acct

Not Req

2,417.72
430.48
430.48
430.48
225.03
15.09
125.71
125.71
125.71
125.71
125.71
125.71
125.71
125.71

Documentation

68.57

79.00000000
105.00000000
105.00000000
105.00000000
105.00000000
105.00000000
35.00000000
35.00000000
35.00000000
35.00000000
35.00000000
35.00000000
35.00000000
35.00000000

35.00000000
TOTAL (Local Curr)

Out. Adv.
60 Day
Dup. Pmt.
Spouse Form (if app.)
Proof of Pmt
Business Purpose Totals

Required
Required
Required
Required
Required
Not Req
Required
Required
Required
Required
Required
Required
Required
Required

BDT
PKR
PKR
PKR
PKR
PKR
THB
THB
THB
THB
THB
THB
THB
THB

401,657.86

540201
540201
540201
540251
540251
540251
540251
540251
540251
540251
540251
540251
540251
540251
540251
540251

191,000.00
45,200.00
45,200.00
45,200.00
23,628.30
1,584.00
4,400.00
4,400.00
4,400.00
4,400.00
4,400.00
4,400.00
4,400.00
4,400.00

$
Department (Cost Center)
Approval:

Today's Date: 31-Dec-16

5,373.40

TOTAL US$

* Date:

Disclaimer
*By signing this document, I confirm the accuracy of all calculations and that appropriate documentation (i.e., receipts or proof of payment) has been submitted and is in compliance with Rotary expense reimbursement guidelines.
Documentation is required for any expense equal to or over US$75 (Rotarian)** / US$25 (staff)** and for all lodging expenses.
Expense statements must be submitted within 60 days (Rotarian) / 30 days (staff) of the date on which the expenses were incurred to be eligible for reimbursement.
For air travel, the unused portion or receipt portion of the ticket (and copy of authorization if purchased by source other than RITS) must be attached in order to process this request.
If you have questions about completing this expense statement, click the tab labeled "Instructions" below.
** Note: If your countrys regulations for documentation of expenses are more strict than the Rotary guidelines, please follow those regulations when providing receipts with your expense statement

CLICK HERE TO COMPLETE MORE ROWS OF EXPENSES

Revised Aug 10

Page 1

ROTARY INTERNATIONAL AND ROTARY FOUNDATION EXPENSE STATEMENT

Name:
Rafiq Ahmed Siddique
Rotarian/Staff/Officer
Rotarian
:
Staff Liaison:
Rotary ID:
Address:

Country:
E-mail:

Date

2588663
SIDDIQUES' Apt. # A-1, House # 13,
Road
# 7 Dhaka -1212.
Gulshan-1,

Total Expenses (US$):

Total Advance Amount:

Due to Individual or (Due RI):

Bangladesh

Any Spouse Related Expenses

rafiq@bol-online.com

Payment Option:

Expense
Type

Description/
Business Purpose of Expense

5,373.40

Today's Date: 31-Dec-16

Date(s) Cover

Title/Office:

RRFC, 2014-2017

Location of
Assignment:

Zone 6B

Assignment:

RRFC, 2014-2017

5,373.40

Signature:
Amount of
Expense (in local
currency)

Others Present
(Business Relationship & Number)

401,657.86

Currency

US$
Total

Exchange Rate

TOTAL (Local Curr)

5,373.40

Documentation

For RI Staff Use Only

Cost Ctr - Prod
Acct
Code

TOTAL US$

Disclaimer
*By signing this document, I confirm the accuracy of all calculations and that appropriate documentation (i.e., receipts or proof of payment) has been submitted and is in compliance with Rotary expense reimbursement guidelines.
Documentation is required for any expense equal to or over US$75 (Rotarian)** / US$25 (staff)** and for all lodging expenses.
Expense statements must be submitted within 60 days (Rotarian) / 30 days (staff) of the date on which the expenses were incurred to be eligible for reimbursement.
For air travel, the unused portion or receipt portion of the ticket (and copy of authorization if purchased by source other than RITS) must be attached in order to process this request.
If you have questions about completing this expense statement, click the tab labeled "Instructions" below.

Revised Aug 10

Page 2

ROTARY INTERNATIONAL AND ROTARY FOUNDATION EXPENSE STATEMENT

Name:
Rafiq Ahmed Siddique
Rotarian/Staff/Officer
Rotarian
:
Staff Liaison:
Rotary ID:
Address:

Country:
E-mail:

Date

2588663
SIDDIQUES' Apt. # A-1, House # 13,
Road
# 7 Dhaka -1212.
Gulshan-1,

Total Expenses (US$):

Total Advance Amount:

Due to Individual or (Due RI):

Bangladesh

Any Spouse Related Expenses

rafiq@bol-online.com

Payment Option:

Expense
Type

Description/
Business Purpose of Expense

5,373.40

Today's Date: 31-Dec-16

Date(s) Cover

Title/Office:

RRFC, 2014-2017

Location of
Assignment:

Zone 6B

Assignment:

RRFC, 2014-2017

5,373.40

Signature:
Amount of
Expense (in local
currency)

Others Present
(Business Relationship & Number)

401,657.86

Currency

US$
Total

Exchange Rate

TOTAL (Local Curr)

5,373.40

Documentation

For RI Staff Use Only

Cost Ctr - Prod
Acct
Code

TOTAL US$

Disclaimer
*By signing this document, I confirm the accuracy of all calculations and that appropriate documentation (i.e., receipts or proof of payment) has been submitted and is in compliance with Rotary expense reimbursement guidelines.
Documentation is required for any expense equal to or over US$75 (Rotarian)** / US$25 (staff)** and for all lodging expenses.
Expense statements must be submitted within 60 days (Rotarian) / 30 days (staff) of the date on which the expenses were incurred to be eligible for reimbursement.
For air travel, the unused portion or receipt portion of the ticket (and copy of authorization if purchased by source other than RITS) must be attached in order to process this request.
If you have questions about completing this expense statement, click the tab labeled "Instructions" below.

Revised Aug 10

Page 3

ROTARY INTERNATIONAL AND ROTARY FOUNDATION EXPENSE STATEMENT

Name:
Rafiq Ahmed Siddique
Rotarian/Staff/Officer
Rotarian
:
Staff Liaison:
Rotary ID:
Address:

Country:
E-mail:

Date

2588663
SIDDIQUES' Apt. # A-1, House # 13,
Road
# 7 Dhaka -1212.
Gulshan-1,

Total Expenses (US$):

Total Advance Amount:

Due to Individual or (Due RI):

Bangladesh

Any Spouse Related Expenses

rafiq@bol-online.com

Payment Option:

Expense
Type

Description/
Business Purpose of Expense

5,373.40

Today's Date: 31-Dec-16

Date(s) Cover

Title/Office:

RRFC, 2014-2017

Location of
Assignment:

Zone 6B

Assignment:

RRFC, 2014-2017

5,373.40

Signature:
Amount of
Expense (in local
currency)

Others Present
(Business Relationship & Number)

401,657.86

Currency

US$
Total

Exchange Rate

TOTAL (Local Curr)

5,373.40

Documentation

For RI Staff Use Only

Cost Ctr - Prod
Acct
Code

TOTAL US$

Disclaimer
*By signing this document, I confirm the accuracy of all calculations and that appropriate documentation (i.e., receipts or proof of payment) has been submitted and is in compliance with Rotary expense reimbursement guidelines.
Documentation is required for any expense equal to or over US$75 (Rotarian)** / US$25 (staff)** and for all lodging expenses.
Expense statements must be submitted within 60 days (Rotarian) / 30 days (staff) of the date on which the expenses were incurred to be eligible for reimbursement.
For air travel, the unused portion or receipt portion of the ticket (and copy of authorization if purchased by source other than RITS) must be attached in order to process this request.
If you have questions about completing this expense statement, click the tab labeled "Instructions" below.
** Note: If your countrys regulations for documentation of expenses are more strict than the Rotary guidelines, please follow those regulations when providing receipts with your expense statement

Revised Aug 10

Page 4

Rotary International and Rotary Foundation Expense Statement Instructi

Please read the instructions below for assistance in completing the expense statement.
For additional information related to submitting an expense statement, please Guidelines for Submitting Expense Statements
Section 1 - Identifying Information (top of form)
Name
Enter your name
Rotarian/Officer/Staf Select *Rotarian, *Officer, or Staf from the drop-down list (you must make a selection in order to choose an expense type in Section 2)
*For more information about payment options, s Payment Guidelinesor Payment Guidelines FAQ
Staf Liaison
For Rotarian/Officer, enter the name of the staff liaison for your assignment
Rotary ID
For Rotarian/Officer, enter your Rotary ID (if you know it)
Address
Enter your mailing address (if staff, enter your department name)
Country
Enter your country (must be selected for the payment option drop-down to work properly)
E-mail
Enter your e-mail address
Total Expenses (US$) Excel automatically calculates total (if you are not using Excel, you must calculate total manually)
Total Advance AmounEnter amount of advance received in US$ (if applicable)
Due to Individual
Excel automatically calculates amount (or manually calculate)
or (Due RI)
Spouse-Related
Select Yes or No from the drop-down. For more information about spouse-related expenses
Expenses
see the explanation under "Others Present" below
Payment Option
Select Electronic Funds Transfer, Check, or Contribute to TRF
For EFT, ensure that Rotary has your bank account information*
For Contribute to TRF, complete the TRF Contribution Form**
*Rotarian Payee Information Form
**TRF Contribution Form
Today's Date
Excel automatically enters the date (or manually enter)
Date(s) Covered
Include dates of trip or date of expense(s) incurred
Title/Office
Enter the Rotary title or office held (e.g., president's rep, RRFC)
Location(s)
Enter the city and country where expenses were incurred
Assignment
State the main business purpose for trip or expense. (Note: You should complete a separate expense statement for each Rotary assignment.)
Signature
Do not sign the form until you've completed all sections and reviewed for accuracy/completeness
Section 2 - Business Expense Information (middle of form)
Please complete the following information for each expense. List expenses in chronological order.
Note - the description fields are limited to 50 characters. If you need to enter more information, please just continue on the next line.
Date
Enter the date on which the expense was incurred
Expense Type
Select the appropriate expense category from the drop-down list
Description/Business Describe business purpose of the expense (e.g., hotel at convention; dinner with Trustees; etc.)
Purpose of Expense If claiming personal auto expenses, enter a brief description including the total number of miles/kms traveled and your calculation based
on RI Mileage Reimbursement Rates
(you may provide a printout from an Internet map site such as Google Maps, MapQuest, etc.).
Note: Personal auto expenses exceeding US$250 roundtrip require prior approval from RITS.
Others Present
State the business relationship and number of other participants whose costs are included in the request (if applicable)
(Relationship, Numbe Note: If claiming spousal expenses, be sure to completSpouse Form
A spousal expense is any expense (e.g. meals, registrations) for which you are claiming reimbursement for your spouse
Please be aware that to be reimbursed by Rotary, spousal expenses must have a documented bona fide business purpose.
Amount of Expense List the amount of the expense in local currency
Currency
Select the appropriate currency code from the drop-down list, or enter currency code
Exchange Rate
Enter the exchange rate on the date the expense was incurred. Provide documentation to substantiate exchange rate used.
If rate is unavailable, RI rate will be used.
Note: This form uses the formula of Currency per USD (e.g., 0.60 GBP = 1 USD rather than 1 GBP = 1.66666667 USD.
This means you would need to enter 0.60 in the exchange rate field rather than 1.66666667).
For additional information about using exchange rates, se Guidelines for using RI exchange rates on expense statements

Revised July 09

US$ Total
Documentation

Grand Total
Total US$

Excel automatically calculates total (or calcuate manually)

Excel automatically identifies whether documentation (e.g., receipts, canceled checks with the bill/invoice)
is required (equal to and over $75 for Rotarians/equal to and over $25 for staff/hotel folio regardless of amount).
Documentary evidence is usually considered adequate if it shows the name, location, amount, date, and essential character of the expense. See
Valid Proof of Payment
guidelines for more information.
Note: If your countrys regulations for documentation are more strict than the Rotary guidelines, please follow those regulations when submitting receipts.
Please refer to theAdditional
Additional
Documentation
Requirements
Guidelines
guidelines for more information
Documentation
Requirements
by Country
Excel automatically calculates total (or calculate manually)
Excel automatically calculates total (or calculate manually)

NOTE: If your expenses exceed the number of rows available on the first page, please click the link at the bottom to complete more rows of expenses.
Clicking this link will bring you to an additional expense statement worksheet.
Final Steps:
Once you've completed the expense statement, please review for accuracy, sign/date, print, and forward to the appropriate staff liaison/manager for approval.
Note: By signing this expense statement, the requestor is attesting that all items are reasonable and necessary business-related expenses incurred while conducting
authorized Rotary business.

Click here to fill out Expense Statement

Revised July 09