Reimbursement Claim Form

Employee Id : 00080621 Employee Name : Shankha Shubra Ghosh

Reference Date : 13.03.2015 Reference No : 0000011217

Car Fuel & Maintenance

Bill Number Particulars Bill Date Bills Submitted
228 PETROL @ RS. 65.90/- FOR 30.3 04.03.2015 2,000
40 PETROL @ RS. 65.19/- FOR 41.2 18.02.2015 2,690.39
81072 PETROL @ RS. 65.90/- FOR 22.7 13.03.2015 1,500
846486 PETROL @ RS. 65.90/- PER LTR 28.02.2015 1,900
Sub Total 8090.39

Grand Total 8090.39

I declare that above reimbursement claims submitted by me shall be considered for payroll purpose.

Claim Date Signature

16.03.2015 Shankha Shubra Ghosh