MINNESOTA STATE COLLEGES AND UNIVERSITIES
Mesabi Range College
1
001 Chestnut Street West
Virginia, MN 55792-3401
AFFIDAVIT FOR EMPLOYEE REIMBURSEMENT
State of Minnesota
County of
, being first duly sworn, says that
he/she is an employee of the State of Minnesota, Minnesota State Colleges and Universities, and
that on
, 20
, he/she
to
for which a sum of $
was paid.
Paid a registration fee of $
to
Secured lodging at
in
for which a sum of $
was paid.
for which a sum of $
was paid.
And further, that a receipt was not obtained for the above expenditure(s).
And further, that a receipt was obtained but that it was lost.
Th
is expense was incurred as an employee of the State of Minnesota on official business.
Subscribed and sworn before me this
day of
, 20
Employee Signature
Notary Public
County, Minnesota
My commission expires
Affi
davit
11/15/05
Updated August 2012
Updated March 2014 (fillable .pdf)
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