|
Name
|
| |
Todd Test
|
|
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 |
$5.00 |
$5.00 |
$5.00 |
$5.00 |
$5.00 |
$5.00 |
$5.00 |
$5.00 |
$35.00 |
| Monday |
$12.00 |
$121.00 |
$1.00 |
|
$1.00 |
$1.00 |
$1.00 |
$1.00 |
$126.00 |
|
$17.00 |
$126.00 |
$6.00 |
$5.00 |
$6.00 |
$6.00 |
$6.00 |
$6.00 |
$161.00 |
|
|
Expense Sub Total
|
| |
$161.00
|
|
Fee Sub Total
|
| |
$17.00
|
|
Total Claim Submission
|
| |
$178.00
|
|
Claim Confirmation
|
| |
 I, Todd Test agree the above amount to be accurate.
|
|