EXPENSE CLAIM FORM

900173
Employee ID:
Month:Dec
Ashish Kumar Mishra
Employee Name:

Expense Details to be filled by an Employee (One row per invoice/ bill)

Amount In
S.No. Date/ Period Particulars INR Remark/s (Name of Vendor)

Expenses Name -
1.00 8-Dec Uniform Bill 9,900.00 RoopRang
2.00 24-Dec Food Bills 621.00 Pizza Hut
3.00 3-Oct Food Bills 1,500.00 Bikanerwala

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-
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-
-
-
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-
-
Totals 12,021.00

Expenses Summary (Not to be filled by the Employees)

No. of Bills
Particulars Amount In INR
Attached
Medical Bill - -
Telephone / Internet Bill - -
Fuel Bill - -
Uniform Bill 1 9,900.00
Books & Periodicals Bill - -
Driver - -
Food Bills 2 2,121.00
Taxi Bills - -
Hotel Bills - -
Vehicle Repair Bills - -
Totals 3.00 12,021.00

Notes:
1. The expenses claimed must not exceed the limit under different heads of your Compensation Structure.
2. This form is to be filled, printed and submitted to Accounts on or before last working day of the month.
3. All the original bills are to be submitted along with this Reimbursement Calim Form.
4. These claims have strict guidelines from the Income Tax Department. It is purely an Accounts discretion for any claim to be approved.
5. Timely submission is a must failing which, the salary will be credited without considering the benefits. Taxes will be deducted in such cases
as applicable.

Declaration: I hereby declare the bills attached are original and expensed by me.

Employee Signature
Name:
Date/ Place: