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(Governmental Unit)
NAMEDr.
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(Office Board, Department or Institution)
On Account Of Appropriation No. For
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DateFROMTOSPEEDOMETER READING*NATURE OF BUSINESSAUTO MILES TRAVELEDMILEAGE _$.725_ RATEMILES REIMBURSED
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PointPointStartFinish
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7253$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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$0.7250$0.00
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Auto License No.TOTALS:0$0.7250$0.00
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*SPEEDOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map. Pursuant to the provisions and penalties of Chapter 155. Acts 1953. I hereby certify that the foregoing account is just and correct that the amount claimed is legally due after allowing all credits and that no part of the same has been paid.
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ACS Business Office
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