SELF-CERTIFICATION EXPENSE CLAIM FORM:

Per global policy 0063 Time and Expense Reporting, an employee may self-certify an expense in the absence of an original expense receipt, providing a copy of the
receipt cannot be obtained and a credit card was not used, Required information includes the date the expense was incurred, the description and reason for the expense,
if applicable any individuals who attended (number and names) and the amount, which is not to exceed USD $100 per occurrence. This form is to be approved and signed
by the employees Primary Reviewer of his/her time and expense report.

Enterprise ID
Personnel No.
Level:
Period ending:

Please complete in full detail the expenses claimed in the table below:
Date
Expense
Incurred

Description of Expense

Reason for Expense

Individuals in Attendance

Amount

Total:
Employee declaration: I certify that all of the expenses recorded above were properly incurred in accordance with Accenture policies and procedures,
including policy 0063.
Signature:

Date:

Primary Reviewer Approval: I certify that I have reviewed the above self-certified expenses, and am satisfied from the information provided that all
expenses have been properly incurred in accordance with Accenture policies and procedures, including policy 0063
Signature:

Date: