Pleasanton Unified School District
4665 Bernal Avenue • Pleasanton, California 94566
MILEAGE AND EDUCATIONAL EXPENSE CLAIM
EMPLOYEE ID EMPLOYEE NAME SCHOOL/DEPARTMENT/MAILING ADDRESS
CLAIM FOR THE MONTH OF
DA
TE
DESTINATION OR
TYPE OF EDUCATIONAL EXPENSE
MILES
SIGNATURE: __________________________________________ __________
Employee Date
APPROVED: __________________________________________ __________ _____________________ ___________
Principal or Administrator Date Business Oce Approval Date
DISTRIBUTION: ACCOUNTING: Originals with Original Signatures ORIGINATOR: Print and Retain Copy
NOTE: Expense Claims submitted after 30 days may NOT be reimbursed.
ACCOUNT # ___________________________________________________________________________________________________________
ACCOUNT # ___________________________________________________________________________________________________________
TOTAL MILEAGE
AMOUNT PER MILE
X TOTAL MILEAGE
TOTAL EXPENSES
TOTAL CLAIM
I HEREBY CERTIFY THAT THE ABOVE-CLAIMED EXPENSES ARE TRUE AND
CORRECT AND WERE ON OFFICIAL SCHOOL BUSINESS.
ORIGINAL, ITEMIZED RECEIPTS ARE REQUIRED FOR ALL EXPENSES OTHER
THAN MILEAGE.
FOR MEALS, LIST NAME(S) OF PERSONS OTHER THEN THE CLAIMANT.
TRAVEL REIMBURSEMENT REQUIRES TRAVEL ADVANCE APPROVAL FORM.
OTHER
EXPENSES
