Check...Submit
Please check the content of your expense report carefully. If any changes need made, press the 'Edit' button.
WEEK OF: %weekof% |
RATE: %rate% |
EMPLOYEE: %employee_name% (%employee_id%) |
CONSUMER: %consumer_name% (%consumer_id%) |
%date1% |
%begin1% |
%end1% |
%miles1a% miles |
start: %start1% |
to: %destination1% |
%date1% |
%begin1a% |
%end1a% |
%miles1b% miles |
start: %start1a% |
to: %destination1a% |
%date2% |
%begin2% |
%end2% |
%miles2a% miles |
start: %start2% |
to: %destination2% |
%date2% |
%begin2a% |
%end2a% |
%miles2b% miles |
start: %start2a% |
to: %destination2a% |
%date3% |
%begin3% |
%end3% |
%miles3a% miles |
start: %start3% |
to: %destination3% |
%date3% |
%begin3a% |
%end3a% |
%miles3b% miles |
start: %start3a% |
to: %destination3a% |
%date4% |
%begin4% |
%end4% |
%miles4a% miles |
start: %start4% |
to: %destination4% |
%date4% |
%begin4a% |
%end4a% |
%miles4b% miles |
start: %start4a% |
to: %destination4a% |
%date5% |
%begin5% |
%end5% |
%miles5a% miles |
start: %start5% |
to: %destination5% |
%date5% |
%begin5a% |
%end5a% |
%miles5b% miles |
start: %start5a% |
to: %destination5a% |
%date6% |
%begin6% |
%end6% |
%miles6a% miles |
start: %start6% |
to: %destination6% |
%date6% |
%begin6a% |
%end6a% |
%miles6b% miles |
start: %start6a% |
to: %destination6a% |
%date7% |
%begin7% |
%end7% |
%miles7a% miles |
start: %start7% |
to: %destination7% |
%date7% |
%begin7a% |
%end7a% |
%miles7b% miles |
start: %start7a% |
to: %destination7a% |
TOTAL MILES: %totalmiles% |
AMOUNT: $%amount% |
(Please be aware that the "Total Miles" and "Amount" indicated above will be reduced if more miles are driven per
month than are approved in the consumer's plan of care...or if the reason for travel falls outside of waiver guidelines.)
Employee Electronic Signature: %ESignature%
(I certify that my expense report is accurate and true...that I drove these exact miles with the Waiver Recipient named above.)
Consumer/Guardian Signature:________________________________________
(I attest by my signature that the Waiver Staff named above provided transportation to the places indicated.)
%_sfm_edit_button_% %_sfm_confirm_button_%