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DEPARTMENT OF NATURAL RESOURCES <br />NON EMPLOYEE TRAVEL EXPENSE REIMBURSEMENT <br />DIVISION NAME and CODE: RECLAMATION, MINING AND SAFETY/PKAA I MONTH April YEAR 2017 <br />$127.28 <br />TRAVEL <br />MILEAGE <br />MEALS AND LODGING <br />Date <br />From <br />To <br />Time <br />Depart <br />Time <br />Arrive <br />No. Miles <br />Rate Per <br />Mile * <br />Total <br />Brkfst Lunch <br />Dinner <br />Lodg. <br />Total <br />Total <br />Reimb. <br />Items <br />4/27/2017 <br />PARKER <br />DENVER <br />7:30 AM <br />1 <br />34.00 <br />$0.48 <br />$16.32 <br />$0.00 <br />$16.32 <br />4/27/2017 <br />DENVER <br />PARKER <br />7:00 PM <br />34.00 <br />$0.48 <br />$16.32 <br />$0.00 <br />$16.32 <br />34.00 <br />$0.48 <br />$16.32 <br />$0.00 <br />$16.32 <br />34.00 <br />$0.48 <br />$16.32 <br />$0.00 <br />$16.32 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.48 <br />$0.00 <br />$0.00 <br />$0.00 <br />TOTALS <br />$65.28 <br />$0.00 $0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$65.28 <br />MISCELLANEOUS EXPENSES Misc. <br />MLRB Board Meeting $50.00 TRAVEL ADVANCE <br />Parking $12.00 <br />Total Misc $62.00 TOTAL <br />$62.00 <br />$0.00 <br />$127.28 <br />BUSINESS PURPOSE OF TRIP: MINED LAND RECLAMATION BOARD MEETING <br />CERTIFICATION: I certify that I actually paid for and received the goods or services, and these expenses are for official State Business. I certify that the details above are true and <br />correct in all respects; that payment of the amounts claimed herein has not and will not be reimbursed to me or has paid by any other sources; this request does not include expenses o <br />a personal or political nature or for any other expenses not authorized by the Fiscal Rules; I actually incurred or paid the operating expenses of the motor vehicle for which <br />reimbursement is claimed on a mileage basis; I have a valid driver's license and adequate insurance coverage. Further, I hereby authorize the State to deduct from my pay any amount <br />id to me in excess of my authorized expenses, as provided by Fiscal Rule 5-1 and travel polic t. I understand a portion of the reimbursement may be treated as taxable income. <br />PAYEE SIGNATURE <br />DATE <br />VENDOR CUSTOMER NUMBEI 51790 <br />PAYEE NAME (PRINTED) <br />THOMAS E. BRUBAKER <br />MAILING ADDRESS <br />❑� Check Here if you want Electronic Funds Transfer EFT <br />APPROVAL <br />APPROVING AUTHORITY - Travel and Other Expense reimbursement requested above, represent work performed on behalfof the Department, is reasonable and necessary to <br />achieve program objectives, expenses have been kept to a minimum and are in compliance with Fiscal Rules. Reimbursement is approved as submitted. <br />Camille Mojar <br />SUPERVISOR NAME (PRINTED) SUPERVISOR SIGNATURE DATE <br />FUND DEPT Div UNIT SubUNIT APPR OBJ SUB OBJ DEPT OBJ LOC ACTIVITY TASK PRGM AMOUNT <br />2560 PKAA 1000 PCAAEMINO 2523 MILEAGE $65.28 <br />2560 PKAA 1000 PCAAEMINO 2520 PARKING $12.00 <br />2560 PKAA 1000 PCAAEMINO 1330 PERDIEM $50.00 <br />2560 PKAA 1000 PCAAEMINO 2522 LGIN HOTEL $0.00 <br />25600 1 1 PCAAEMINO 12522 1 IMEIN IMEALS <br />100 <br />$127.28 <br />