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PORTLAND
P.O. Box 6800
Scarborough, Maine 04070-6800
LWOP & EXPENSE VOUCHER
NAME:__________________________________________________________________________________
ADDRESS____________________________CITY:_______________________STATE:________ZIP:_________
PURPOSE:______________________________________ FUNCTION DATES:___________________________
HOTEL:/Days:__________Attach receipt $____________________
TRANSPORTATION (Circle one) PLANE/CAB $____________________
AUTO: # Miles_____________ at 58.5 cents per mile $____________________
TOLLS: $____________________
MEAL EXPENSE: (Attach receipts) $____________________
SECTION ONE: TOTAL EXPENSE $____________________
MISCELLANEOUS EXPENSES
Postage:__________Phone:___________Supplies:____________Other:____________
Misc:____________Tips:____________Registrations:__________________________
SECTION TWO: TOTAL EXPENSE $____________________
COMPENSATION SECTION
LEVEL/STEP: __________________ GROSS PAY: $____________________
HOURLY RATE OF PAY: __________________ SOC SEC: $____________________
DATE OF LWOP: ___________________(attach 3971) MEDICARE: $____________________
DATE OF OTHER LEAVE: __________________ FEC TAX: $____________________
#HRS NIGHT DIFF __________________ ME. TAX: $____________________
SECTION THREE NET PAY: $____________________
1:ALL EXPENSE VOUCHERS MUST BE SIGNED TOTAL SECTION 1: $____________________
2: 3971” MUST BE ATTACHED TOTAL SECTION 2: $____________________
3: RECEIPTS REQUIRED FOR ALL EXPENSES TOTAL SECTION 3 $____________________
LESS ADVANCES: $____________________
AMT DUE EMPLOYEE
$____________________
SIGNATURE:________________________TITLE:_____________________DATE:____________________
APPROVED BY:______________________DATE:_____________________CHK#________________________
AUTHORITY:___________________________________________________________________________________
Rev (07/1/2008)
