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<br />STATE OF COLORADO <br />TRAVEL EXPENSE <br /> <br />..,.",., <br /> <br />DEPARTMENT <br /> <br />Month <br /> <br />19_ <br /> <br />DIVISION OR AGENCY <br /> <br /> TRAVEL MILEAGE MEALS AND LODGING <br />Date Time Time No. Rate Total <br /> Reimbur <br /> FROM TO Depart Return Miles Per Total Bkst. Lunch Dinner Lodg. Total Items <br /> Mile <br /> $ $ $ $ $ $ $ <br />TOTALS $ $ $ $ $ $ $ <br />MISCELLANEOUS EXPENSE: $ <br /> LESS TRAVEL ADVANCE $ <br /> TOTAL $ <br /> <br />'URPOSE OF TRIP: <br /> <br />ERSONS AND AGENCIES CONTACTED: <br /> <br />"I certify that the statements in the above schedule are true and just in all respects; that payment of the amounts claimed herein has not and will not <br />be reimbursed to me from any other sources; that travel performed for which reimbursement is claimed was performed by me on State business and <br />that no claims are included for expenses of a personal or political nature or for any other expenses not authorized by the Fiscal Rules; and that I <br />actually incurred or paid the operating expenses of the motor vehicle for which reimbursement is claimed on a mileage basis." <br /> <br />PAYEE <br /> <br />TITLE <br /> <br />DATE <br /> <br />MAIL ADDRESS <br /> <br />RECOMMENDED FOR APPROVAL <br /> <br />Fiscal Officer <br /> <br />Supervisor <br /> <br />:-02 (11 <br />'" 2-70 (Rev. 2/91) <br />,-53-06-0029 <br /> <br />Executive Director <br />