ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAH
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EDUCATIONAL SERVICE DISTRICT #123
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Name & Address of Claimant
Duty Station
TRAVEL EXPENSE VOUCHER
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(Mileage Rate as of October 2023)
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Month/Year
Approved By:
Checked for Payment By:
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Trip InformationReimbursment BasisMotor VehiclePer Total OtherNON-TAXAmount
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TRIP TIMEPer Meal EntitlementMiles DrivenMile Mile ExpenseTRAVELSubject toPURPOSE OF TRIP
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DATEFROMTODEPARTRETURNBREAKFASTLUNCHDINNERLODGINGPT TO PTVICINITYRate Cost ($) Per Detail*TOTALPayroll Tax
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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 0.670 $ - $ -
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TOTALS:0.000.000.000.000.000.000.000.000.000.00
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*DETAIL OF OTHER EXPENSE CODE DISTRIBUTION
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I hereby certify under penalty of perjury that this is a true and correct claim for
DatePaid ToForAmountAccount CodeTaxableNon-Taxable
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necessary expenses incurred by me and that no payment has been received
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by me on account thereof.
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SignatureDate
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Title
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TOTAL $ - $ -
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