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Name
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Todd Demo Claim
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Clinic
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Chicago
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Week
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05/14/2023
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Currency of Claim
|
| |
USD
|
| Expenses For Claim |
|
Expenses
|
| |
| Date |
Fee |
Meal per diem |
Air Fare |
Hotel |
Car Rental |
Taxi |
Parking |
Other |
Expenses |
| Sunday |
$250.00 |
$50.00 |
$50.00 |
$50.00 |
$50.00 |
$1.00 |
$1.00 |
$2.00 |
$204.00 |
| Monday |
0 |
0 |
0 |
0 |
$10.00 |
0 |
0 |
0 |
$10.00 |
|
$250.00 |
$50.00 |
$50.00 |
$50.00 |
$60.00 |
$1.00 |
$1.00 |
$2.00 |
$214.00 |
|
|
Expense Sub Total
|
| |
$214.00
|
|
Fee Sub Total
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| |
$250.00
|
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Total Claim Submission
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| |
$464.00
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Comments
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This is a demo claim. Email me Fred to confirm you received this email.
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Claim Confirmation
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 I, Todd Demo Claim agree the above amount to be accurate.
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