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I Travel FeohTTravel T <br />To I <br />I P <br />Per Diem Rate (enter under Brkfast) or Actual Expenses M <br />Mileage <br />bate � <br />Location L <br />Lodging B <br />Brkfast L <br />Lunch D <br />Dinner O <br />Other M <br />Miles R <br />Rate A <br />Amount A <br />Air Fate T <br />Totai <br />t,/c�� i i <br />Expenses <br />iil�Eii l�f.' � <br />�f AYi�tr6 <br />rr4 <br />�> �f (f r 1 LICA y NIV <br />--- .-- - --- -• n.co c vs <br />approval form and all f eceipts should be sent to the Executive Director, Jerry F. Kenny, at 3710 Central Avenue, Suite E, Kearney, NE 68847. <br />Signature Of of Claimant Date <br />4pprr�vai <br />xecutive Director Date <br />