Annexure to Relmbursement statement

(A) travell statement Date of Travel from : 19-Jan-23 To: 19-Jan-23

(A1) Out station travel- fare /toll taxes
Bill No Date Mode Of travel Purpose of Travel From place To Place Kms Amount
1 19-01-23 Car Branch Visit Lucknow Prayagraj 484 1750

Total (A1) 1750

(A2) Out Station Travel-Stay /Food/others
Bill No Date Name Of hotel /Rest. Details/Purpose of Expenses From place To place Amount
19-01-23 the Patio Food & Drinks Afternoon Lunch Prayagraj Prayagraj 519

Total (A2) 519

A3)Out Station Travel- Conveyance
Bill No Date Mode Of travel Purpose of Travel From place To Place Kms Amount

Total (A3)
Grand Total (AI+A2+A3) 2269/-
B LocalTravel- Conveyance
Bill No Date Mode Of travel Purpose of Travel From place To Place Kms Amount

Total #REFF!
Offical Mobile Reimbursemient
Bill No Bill Date Mobile no Period Bill Ammount Elligible Amt Claim Amt

Total #REFF!
D) Detais of Staff wellare-FoodRelreshment,
Bill No Date Vendor/Hotel Name Details /Purpose of Expenses No of Staff Amount

Total #REFF!
E)Details of Diesel for DG set
Bill No Date Vendor Name Reading Of DG Qunatity (ltr) Rate Of Diesel Amount

Total #REFF!
F) Details of other re-inibursement (please update the details on 1st P'age ngainst relevant E1pense llead)
Bill No Date Vendor Name Details /Purpose of Expenses No of Staff Amount

Total #REFF!

Employee Name & Sign : Ajeet Shilpkar

Employee Code : 231317 Name & Sign OF Approver (With Stamp)