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Production Company

FUEL REIMBURSEMENT
NAME: POSITION:
DEPT: CAR REGO: MAKE/MODEL:

Date

To Whom Paid

Total Excl. GST

Total GST

Amount Incl. GST

1 2 3 4 5 6 7 8 9 10 TOTALS FOR EACH COLUMN BUSINESS KLMS % (as per attached log book record) TOTAL TO BE REIMBURSED ( x Business %) RECEIVED AUTHORISED BY DEPARTMENT HEAD CHECKED BY ACCOUNTING DEPARTMENT APPROVED BY U.P.M. FBT/GST Declaration (also required by Contractors) I, declare that the Fuel Expenses of $ ________________ (business portion only) were incurred by me during the period from ______________ to _____________ 2004, solely for work purposes and under the 'otherwise deductible' rule would have a taxable value of nil. I also declare that I have not claimed an input tax credit for the GST included in this reimbursement on a Business Activity Statement that has been lodged or will be lodged by me in the future. Signed: Date: $ %
(inc GST)

"Production Title"
Production Company ABN:
FUEL REIMBURSEMENT
NAME: POSITION:
DEPT: CAR REGO: MAKE/MODEL:

Date

To Whom Paid

Total Excl. GST

Total GST

Amount Incl. GST

1 2 3 4 5 6 7 8 9 10 TOTALS FOR EACH COLUMN BUSINESS KLMS (estimate app. to this reimbursement) TOTAL TO BE REIMBURSED RECEIVED AUTHORISED BY DEPARTMENT HEAD CHECKED BY ACCOUNTING DEPARTMENT APPROVED BY U.P.M. FBT/GST Declaration (also required by Contractors) I, declare that the Fuel Expenses of $ ________________ $ kms
(inc GST)

were incurred by me during the period from ______________ to _____________ 200 , solely for work purposes and under the 'otherwise deductible' rule would have a taxable value of nil. I also declare that I have not claimed an input tax credit for the GST included in this reimbursement on a Business Activity Statement that has been lodged or will be lodged by me in the future. Signed: Date:

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