Expense Sheet Template 41104

Partial file snippet.

Sheet 1: Exp Report 

	
	
	
	
	
	
	
	
		
 
		
		MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

	
	
		MONTHLY EXPENSE REPORT
		

		

		

		

		

		

		

	
	
		EMPLOYEE NAME (LAST, FIRST)
		FOR MONTH OF
		PAGE
		

		

	
	
		

		

		

		OF
		

	
	
		HOME ADDRESS (if depart from/end day at home)
		DEPARTMENT/DIVISION OR INSTITUTION
		

		

		

		

		

		

	
	
		

		

		
	
		OFFICE ADDRESS
		WORK PHONE NO.
		VENDOR NO (LAST FOUR SSN ONLY)
		
	
		

		

		

		
	
		Grey areas are calculated
		
	
		DATE
		FROM/TO & PURPOSE
		OVER-NIGHT STAY (X)
		RET (X)
		STANDARD MILES
		FLEET MILES
		RENTAL MILES
		BREAK-FAST
		LUNCH
		DINNER
		LODGING
		OTHER*
		TOTAL
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

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		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		TOTALS OF ABOVE »
		0 
		0 
		0 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
	
	
		TOTALS FROM OTHER PAGES »
		0 
		0 
		0 
		0 
		0 
		0 
		0 
		0 
		0.00 
	
	
		TOTAL STANDARD (S) MILES »
		

		0 
		AT
		$0.490 
		PER MILE
		

		

		0.00 
	
	
		TOTAL FLEET (F) MILES »
		

		0 
		AT
		$0.280 
		PER MILE
		

		

		0.00 
	
	
		TOTAL RENTAL (R) MILES »
		

		0 
		AT
		

		PER MILE
		

		

		0.00 
	
	
		TOTAL REIMBURSABLE EXPENSE    »
		$0.00 
		
	
		
	
		DATE
		EXPLANATION OF OTHER *
		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		I hereby certify the above claim is correct, that these expenses were necessary to conduct state business, that payment has been made from personal funds for which I have not been reimbursed, nor will I receive from any source any payment for these expenses.
		
	
		APPROVAL SIGNATURE
		

		

		

		

		CLAIMANT SIGNATURE
		

		

		

		

		

		DATE
		

	
	
		

		

		

		
	
		APPROVAL NAME (PLEASE PRINT OR TYPE)
		

		

		

		

		CLAIMANT  NAME (PLEASE PRINT OR TYPE)
		

		

		

		

		

		

		

	
	
		

		

		
	
		TITLE
		

		DATE APPROVED
		

		

		TITLE
		

		

		

		

		

		OFFICIAL DOMICILE
		

	
	
		

		

		

		

		
	
		PREPARED BY
		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		
	
		MO 580-2347E (7-20)
		

		

		

		

		

		

		

		

		

		

		

		DHSS-DA-57 (11-21)
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	



Sheet 2: Exp Report  pg2

	
	
	
	
	
	
	
	
		
 
		
		MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

	
	
		MONTHLY EXPENSE REPORT
		

		

		

		

		

		

		

	
	
		EMPLOYEE NAME (LAST, FIRST)
		FOR MONTH OF
		PAGE
		

		

	
	
		0
		January-04
		2
		OF
		0
	
	
		HOME ADDRESS  (if depart from/end day at home)
		DEPARTMENT/DIVISION OR INSTITUTION
		

		

		

		

		

		

	
	
		0
		0
		
	
		OFFICE ADDRESS
		WORK PHONE NO.
		VENDOR NO (LAST FOUR SSN ONLY)
		
	
		0
		-
		0
		
	
		Grey areas are calculated
		
	
		DATE
		FROM/TO & PURPOSE
		OVER-NIGHT STAY (X)
		RET (X)
		STANDARD MILES
		FLEET MILES
		RENTAL MILES
		BREAK-FAST
		LUNCH
		DINNER
		LODGING
		OTHER*
		TOTAL
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

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		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		TOTALS OF ABOVE »
		0 
		0 
		0 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
	
	
		TOTALS FROM OTHER PAGES »
		0 
		0 
		0 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
	
	
		TOTAL STANDARD (S) MILES »
		

		0 
		AT
		$0.490 
		PER MILE
		

		

		0.00 
	
	
		TOTAL FLEET (F) MILES »
		

		0 
		AT
		$0.280 
		PER MILE
		

		

		0.00 
	
	
		TOTAL RENTAL (R) MILES »
		

		0 
		AT
		

		PER MILE
		

		

		0.00 
	
	
		TOTAL REIMBURSABLE EXPENSE    »
		$0.00 
		
	
		
	
		DATE
		EXPLANATION OF OTHER *
		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		I hereby certify the above claim is correct, that these expenses were necessary to conduct state business, that payment has been made from personal funds for which I have not been reimbursed, nor will I receive from any source any payment for these expenses.
		
	
		APPROVAL SIGNATURE
		

		

		

		

		CLAIMANT SIGNATURE
		

		

		

		

		

		DATE
		

	
	
		

		

		1/1/1904
		
	
		APPROVAL NAME (PLEASE PRINT OR TYPE)
		

		

		

		

		CLAIMANT  NAME (PLEASE PRINT OR TYPE)
		

		

		

		

		

		

		

	
	
		0
		0
		
	
		TITLE
		

		DATE APPROVED
		

		

		TITLE
		

		

		

		

		

		OFFICIAL DOMICILE
		

	
	
		0
		1/1/1904
		1/1/1904
		0
		
	
		PREPARED BY
		

		

		

		

		

		

		

		

		

		

		

		

	
	
		0
		
	
		MO 580-2347E (7-20)
		

		

		

		

		

		

		

		

		

		

		

		DHSS-DA-57 (11-21)
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

	



Sheet 3: Exp Report  pg3

	
	
	
	
	
	
	
	
		
 
		
		MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

	
	
		MONTHLY EXPENSE REPORT
		

		

		

		

		

		

		

	
	
		EMPLOYEE NAME (LAST, FIRST)
		FOR MONTH OF
		PAGE
		

		

	
	
		0
		January-04
		3
		OF
		0
	
	
		HOME ADDRESS  (if depart from/end day at home)
		DEPARTMENT/DIVISION OR INSTITUTION
		

		

		

		

		

		

	
	
		0
		0
		
	
		OFFICE ADDRESS
		WORK PHONE NO.
		VENDOR NO (LAST FOUR SSN ONLY)
		
	
		0
		-
		0
		
	
		Grey areas are calculated
		
	
		DATE
		FROM/TO & PURPOSE
		OVER-NIGHT STAY (X)
		RET (X)
		STANDARD MILES
		FLEET MILES
		RENTAL MILES
		BREAK-FAST
		LUNCH
		DINNER
		LODGING
		OTHER*
		TOTAL
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

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		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		0.00 
	
	
		TOTALS OF ABOVE »
		0 
		0 
		0 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
	
	
		TOTALS FROM OTHER PAGES »
		0 
		0 
		0 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
		0.00 
	
	
		TOTAL STANDARD (S) MILES »
		

		0 
		AT
		$0.490 
		PER MILE
		

		

		0.00 
	
	
		TOTAL FLEET (F) MILES »
		

		0 
		AT
		$0.280 
		PER MILE
		

		

		0.00 
	
	
		TOTAL RENTAL (R) MILES »
		

		0 
		AT
		

		PER MILE
		

		

		0.00 
	
	
		TOTAL REIMBURSABLE EXPENSE    »
		$0.00 
		
	
		
	
		DATE
		EXPLANATION OF OTHER *
		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		

		

		

		

		

		

		
	
		I hereby certify the above claim is correct, that these expenses were necessary to conduct state business, that payment has been made from personal funds for which I have not been reimbursed, nor will I receive from any source any payment for these expenses.
		
	
		APPROVAL SIGNATURE
		

		

		

		

		CLAIMANT SIGNATURE
		

		

		

		

		

		DATE
		

	
	
		

		

		1/1/1904
		
	
		APPROVAL NAME (PLEASE PRINT OR TYPE)
		

		

		

		

		CLAIMANT  NAME (PLEASE PRINT OR TYPE)
		

		

		

		

		

		

		

	
	
		0
		0
		
	
		TITLE
		

		DATE APPROVED
		

		

		TITLE
		

		

		

		

		

		OFFICIAL DOMICILE
		

	
	
		0
		1/1/1904
		1/1/1904
		0
		
	
		PREPARED BY
		

		

		

		

		

		

		

		

		

		

		

		

	
	
		0
		
	
		MO 580-2347E (7-20)
		

		

		

		

		

		

		

		

		

		

		

		DHSS-DA-57 (11-21)

The words contained in this file might help you see if this file matches what you are looking for:

...Sheet exp report missouri department of health and senior services monthly expense employee name last first for month page home address if depart fromend day at departmentdivision or institution office work phone no vendor four ssn only grey areas are calculated date fromto amp purpose overnight stay x ret standard miles fleet rental breakfast lunch dinner lodging other total totals above raquo from pages s per mile f r reimbursable explanation i hereby certify the claim is correct that these expenses were necessary to conduct state business payment has been made personal funds which have not reimbursed nor will receive any source approval signature claimant please print type title approved official domicile prepared by mo e dhssda pg january...

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	MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
	MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
	MONTHLY EXPENSE REPORT
EMPLOYEE NAME (LAST, FIRST)						FOR MONTH OF				PAGE
											OF
HOME ADDRESS (if depart from/end day at home)						DEPARTMENT/DIVISION OR INSTITUTION

OFFICE ADDRESS						WORK PHONE NO.			VENDOR NO (LAST FOUR SSN ONLY)

Grey areas are calculated
DATE	FROM/TO & PURPOSE	OVER-NIGHT STAY (X)	RET (X)	STANDARD MILES	FLEET MILES	RENTAL MILES	BREAK-FAST	LUNCH	DINNER	LODGING	OTHER*	TOTAL
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
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												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
												0.00
TOTALS OF ABOVE »				0	0	0	0.00	0.00	0.00	0.00	0.00	0.00
TOTALS FROM OTHER PAGES »				0	0	0	0	0	0	0	0	0.00
TOTAL STANDARD (S) MILES »					0		AT	$0.490	PER MILE			0.00
TOTAL FLEET (F) MILES »					0		AT	$0.280	PER MILE			0.00
TOTAL RENTAL (R) MILES »					0		AT		PER MILE			0.00
TOTAL REIMBURSABLE EXPENSE »											$0.00
TOTAL REIMBURSABLE EXPENSE »											$0.00
DATE	EXPLANATION OF OTHER *





I hereby certify the above claim is correct, that these expenses were necessary to conduct state business, that payment has been made from personal funds for which I have not been reimbursed, nor will I receive from any source any payment for these expenses.
APPROVAL SIGNATURE					CLAIMANT SIGNATURE						DATE

APPROVAL NAME (PLEASE PRINT OR TYPE)					CLAIMANT NAME (PLEASE PRINT OR TYPE)

TITLE		DATE APPROVED			TITLE						OFFICIAL DOMICILE

PREPARED BY

MO 580-2347E (7-20)												DHSS-DA-57 (11-21)

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