Pari-Mutuel Employees Guild, SEIU Local 280

1838 East Huntington Drive t Duarte, California 91010

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EXPENSE & REIMBURSEMENT FORM

This FORM must be submitted by Claimant With receipts and itemization of all out-of-pocket expenses to the Secretary/Treasurer. By signing below, Claimant represents that all expenses are in direct support of Local 280 and does not include items of a personal nature.

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Name ____________________________________ Date Submitted _________________ 20__

Address ___________________________________________________________ Apt/Space # ____

City ______________________________________ State ________________ Zip Code ________

Social Security # _________________ Phone # (___) ____-____ Seniority Number _______

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Date Location Description Type Amount

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Total Expenses $ ______

Acting Business Agent Expenses

Date ___________________ 20___.

Track/Satellite ____________________________ A.B.A. Days ____ Rate Per Day ____ Amount $ ________

Track/satellite ____________________________ A.B.A. Days ____ Rate Per Day ____ Amount $ ________

Total A.B.A. Expenses $ ________

Auto Mileage

Date ____________________ 20___.

From ____________________ To _____________________ Mileage _____ Per Mile $ .405 Amount $ ________

Total Mileage Expenses $ ________

TOTAL AMOUNT OF THIS CLAIM $ _____________

Signature of Claimant __________________________________________

IMPORTANT: CLAIMS WILL NOT BE PAID UNLESS SUBSTANTIATED BY

ORIGINAL RECEIPTS OR DETAILED ITEMIZATION!

A.B.A’S PAY RATE - Less than 7 clerks, $1.00 Per Day - 7 to 30 clerks, $5.00 Per Day - 31 clerks or more, $10.00 Per Day

SYMBOLS FOR TYPE - A. Meals & Beverages B. Lodging & Tax C. Airfare D. Fuel E. Parking & Tolls F. Taxi or Bus

G. Supplies H. Printing I. Postage J. Telephone or Fax K. Meeting Expense L. Other (Explain)

(If You need more space, please feel free to use other side of this Expense and Reimbursement Form)

- OFFICE USE ONLY -

Approval Signature _______________________________ Date ______________________ 20___.

Revised 10-24-2005

-SIDE 2-

EXPENSE AND REIMBURSEMENT FORM

FOR ITEMIZING AN EXPENSE OR DETAILING INFORMATION IN SUPPORT OF CLAIM PROVIDE BREAKDOWN:DESCRIPTION OF MEETING, INCLUDING DATES, LOCATION, PER DIEM, NUMBER OF DAYS, AUTO MILES DRIVEN, AUTO ALLOWANCE, ETC. REMEMBER CLAIMS WILL NOT BE PAID UNLESS SUBSTANTIATED BY RECEIPTS OR ITEMIZED!

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PER DIEM: ON-TRACK - $143.00/$136.00, OFF-TRACK - $121.00/$114.00, ON-TRACK NIGHTS - $135.00/$128.00 AND OFF-TRACK NIGHTS $111.00/$104.00.

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- OFFICE USE ONLY-

DATE RECEIVED: ________________________

APPROVED ________ DENIED __________ APPROVED AS REVISED __________

CHECK # ____________ DATE CHECK ISSUED ______________

APPROVED BY ________________________________

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(pmeg)