EXPENSES OTHER THAN TRAVEL, LODGING AND CONVEYANCE - CLAIM FORM

This form must be completed by the employee who has or will claim expenses other than travel/lodging/conveyance and must be submitted to: (i)
Head of Department/Approving authority and (ii) Finance
Please enclose all bill(s)/receipts(s), ticket(s) in original and copy of permit or license obtained, if any along-with this form.
Employee Name Designation and Department SMT
Employee Code Place of Travel (From - To)
Location/Project O&M Company Name
Date of claim 16-08-2017 Bill No. Date/Period of expense Details Total
A. Other Expenses
Cost of License(s)/ permit(s) obtained

Telephone expenses (mention duration of claim in "date of expense")

Photocopy expense
Delhi to West champaran
Courier expense 11-08-2017
Bihar 236.00
Stationery expense

Please specify Other(s), if any

B. Total (A) 236.00

C. Advance given to employee
D. Net Amount (B)-(C) 236.00
E. Amount in words Two hundred thirty six only
Were any expenses incurred on behalf of or to the benefit of
government officials?

Yes No If Yes, please explain.

Certification: Signature of Employee

I confirm that all expenses incurred as mentioned above are related to
the business of the company, are consistent and in compliance with
the Company’s Anti-Bribery and Corruption Policy

To be filed by Relevant Authority

Expense approval details Date Name Signature of
Approver
Designation
Expense review details Date Name Signature of
Reviewer
Designation