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Name and Address of Claimant:
__________________________________________ __________________________________________ __________________________________________ |
Wide Bay School Sport Board PO Box 142 Maryborough 46540 Phone: (07) 4121 1657 Fax: (07) 4121 1658 |
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REIMBURSEMENT OF FUEL EXPENSES
(Use of Private Vehicle for Official Purposes) NB. Please attach a copy of your approval to claim kilometric allowance. Particulars of Claim ENGINE CAPACITY OF VEHICLE: ___________ cc Details of Travel
4/6 cylinder. (over 2000cc) – 13 litres/100km CERTIFICATE OF CLAIMANT I certify that the amount above is due and payable for the goods supplied or the services rendered or described above. Signature _______________________________________ Date ____________________ CERTIFICATE OF TREASURER / SENIOR EXECUTIVE OFFICER (WB School Sport Board) I certify that this payment voucher is in accordance with the particulars on the claim. Signature _______________________________________ Date ____________________ Signature _______________________________________ Date ____________________ PLEASE RETAIN A COPY OF THIS PAYMENT VOUCHER FOR TAXATION PURPOSES |
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