Fuel Expense Claim Form

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FUEL EXPENSE CLAIM FORM

Date: For the month of:

Feb 28, 2013 Feb 2013

Name: Department: Designation:

Entitlement: (Ltr.)

S. # 1 2 3 4 5 6 7 8 9 10

Date

Slip/Bill No.

Litres

Total Amount

Cost per Litre #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Total Claimed

I confirm that the expenses claimed on this form have been actually and necessarily incurred by me, solely for the purpose of business.

Signature of Claimant

NOTE: Original supporting documents, duly signed by claimant, shall be submitted with Finance department for reimbursement by last working day of the month.

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