EXPENSE REIMBURSEMENT CLAIM
COUNTY AUDITOR
GRANT COUNTY, WASHINGTON
Claimant:
Purpose of Claim:
MEALS
Destination:
DATE BF L D IE TOTAL
TOTAL
MILEAGE
DATE FROM (CITY, ST) TO (CITY, ST) MILES RATE TOTAL
TOTAL
CERTIFICATION
I, the undersigned, do hereby certify under penalty of
perjury that the claim is a just, due and unpaid obligation
against the County, and that I am authorized to certify to
said claim.
Claimant Signature: _____________________________
Authorization required for Employees:
ELECTED OFFICIAL, DEPARTMENT HEAD, OR DESIGNEE
Name (printed): ____________________________________________
Signature: ________________________________________________
Date:_____________________________________________________
Authorization required for County Commissioners or Elected Officials:
COUNTY AUDITOR
Name (printed):_____________________________________________
Signature: _________________________________________________
Date:_____________________________________________________
Authorization required
for the County Auditor, Department Heads,
meal expenses outside of travel status, and out of state travel:
COUNTY COMMISSIONERS
Commissioner: _
____________________________________________
Commissioner: _____________________________________________
Chairman BOCC: ___________________________________________
Date:______________________________________________________
HOTELS
DATE OF
CHECK-IN
DATE OF
CHECK-OUT
HOTEL NAME
LOCATION
(COUNTY, ST)
TOTAL
(Receipts required)
OTHER
DATE DESCRIPTION REASON FOR EXPENSE LOCATION (COUNTY, ST) TOTAL
TOTAL
(Receipts required)
Date: _________________________________________
TOTAL REIMBURSEMENT CLAIM:
Claimant’s Department:
