General Form No.

2
Revised January 1992

General Form No. 2

Revised January 1992

REIMBURSEMENT EXPENSE RECEIPT

Date

No.

REIMBURSEMENT EXPENSE RECEIPT

Date

RECEIVED from _______________________________

No.
RECEIVED from _______________________________

(Name)

(Name)

______________________________________ the amount

(Official Designation)

(Official Designation)

of _________________________________ (=P=________)
(In Word s)

______________________________________ the amount

(In Figure)

in payment for ____________________________________

(Payments for subsiste nce, services,

of _________________________________ (=P=________)
(In Word s)

(In Figure)

in payment for ____________________________________

(Payments for subsiste nce, services,

rental or transportation should show inclusive date s,

rental or transportation should show inclusive date s,

purpose, distance, inclusive points of t ravel, etc.)

purpose, distance, inclusive points of t ravel, etc.)

PAYEE

PAYEE

Name/Signature __________________________________

Name/Signature __________________________________

Address _________________________________________

Address _________________________________________

Residence Cert. No. ________________________________

Residence Cert. No. ________________________________

Date of Issue _____________________________________

Date of Issue _____________________________________

Place of Issue ____________________________________

Place of Issue ____________________________________

WITNESS

WITNESS

Name/Signature __________________________________

Name/Signature __________________________________

Address _________________________________________

Address _________________________________________

Residence Cert. No. ________________________________

Residence Cert. No. ________________________________

Date of Issue _____________________________________

Date of Issue _____________________________________

Place of Issue ____________________________________

Place of Issue ____________________________________