|
Name
|
| |
Todd
|
|
Clinic
|
| |
Chicago
|
|
Week
|
| |
05/07/2023
|
|
Currency of Claim
|
| |
USD
|
| Expenses For Claim |
|
Expenses
|
| |
| Date |
Fee |
Meal per diem |
Air Fare |
Hotel |
Car Rental |
Taxi |
Parking |
Other |
Expenses |
| Sunday |
$50.00 |
$50.00 |
$50.00 |
$50.00 |
$50.00 |
$50.00 |
$50.00 |
$50.00 |
$350.00 |
| Monday |
$75.00 |
$1.00 |
$1.00 |
$1.00 |
$1.00 |
$111.00 |
$1.00 |
$1.00 |
$117.00 |
| Tuesday |
$60.00 |
$6.00 |
$60.00 |
$60.00 |
$44.00 |
$44.00 |
$44.00 |
$44.00 |
$302.00 |
|
$185.00 |
$57.00 |
$111.00 |
$111.00 |
$95.00 |
$205.00 |
$95.00 |
$95.00 |
$769.00 |
|
|
Expense Sub Total
|
| |
$769.00
|
|
Fee Sub Total
|
| |
$185.00
|
|
Total Claim Submission
|
| |
$954.00
|
|
Claim Confirmation
|
| |
 I, Todd agree the above amount to be accurate.
|
|