TRAVEL AND SUBSISTENCE ALLOWANCE CLAIM FORM

NAME: TSELISO LECHELA E/N: 171 TITLE: PLANNING AND DEPARTMENT: NQM DUTY STATION: HQ
OPTIMIZATION MANAGER

VEHICLE REGISTRATION VEHICLE TYPE :TOYOTA SRX VEHICLE RATE: VEHICLE ENGINE ACCOUNT/ PROJECT YEAR: 2017 MONTH: OCTOBER
NO:MU820 SIZE IN CC : NUMBER:

Route, Places visited and means of Transport or

MEALS
travel: Departure
Arrival to No: of KM PETROL INCONVENIENCE OTHER PURPOSE OF DUTY
DATE: from ACCOMMODATION TOTALS
(Hour): Travelled ALLOWANCE ALLOWANCE BREAK- EXPENCES TRIP
FROM: TO: (Hour): LUNCH DINNER
FAST

F2 and F3 deployment in
4-Oct-17 MASERU MOKHOTLONG 2PM 7PM 600.00 100.00 700.00 Mokhotlong

F2 and F3 deployment in
5-Oct-17 MOKHOTLONG MASERU 100.00 297.00 397.00 Mokhotlong

TOTAL TRAVEL AND SUBSISTENCE EXPENDITURE 600.00 200.00 297.00 1097.00

I certify that I travelled by my own vehicle.

Passed for payment of: M……………………………. C…………...………..
I got M1397.00 in advance for this duty trip.

Signature:…………………………...…. DATE:……………………………. Signature:…………………………………………………....…. Date:………………..

I certify that I travelled on duty during the stated period above. I received the sum of:
Signature:……………………………………………… Date:……………..……

Signature:…………………………….... DATE:………………………….... Signature:……..………………………………….….…...…...…. Date:………………..

I certify that the this duty trip was duly ordered.
I have not got any advance payment for this duty trip.
Manager:…………..…………………… DATE:…………………………... Authorising Officer:……………………...…………………...…. Date:………………..

I certify that this duty trip was duly Authorised.

Cashier:….…………...………………………………………...…. Date:…………..……

Chief Officer:……………………..…… DATE:…………………………… Cheque Number:…...…………………………..………………... Date:……………..… Signature:………………………………………..…… Date……………………