BATCH NUMBER x-noneDATEx-noneLODGING x-noneYear 201 x-nonemonth/dayx-noneSTARTEDx-noneSTOPPED RATE DESCRIPTION x-noneAMOUNTx-noneTOTAL Object Code x-noneDB Hotel1x-noneDB Hotel2x-noneDB Hotel3x-noneDB Hotel4 x-noneSTATEx-noneZIP CODE x-noneto the provisions of NE State Statutes sections 81-1014 & 81-1176. Updated x-noneI claim reimbursement for the above expenses incurred by me in the line of duty and in accordance with Nebraska State Statutes. I declare that this is x-noneDATE x-noneEMPLOYEE NUMBER x-noneDATE x-nonesuch expenses for which payment has not previously been made by the State of Nebraska or another source. EMPLOYEE SIGNATURE x-noneSUPERVISOR/APPROVER SIGNATURE I certify that reimbursement for use of privately owned vehicles, if claimed, is authorized x-noneHOME ADDRESS x-noneNAME and TITLE x-noneCITY x-noneAmount Business Unit x-noneTOTALS x-none*Please attach your itemized meal receipts to the Meal Receipt Form or blank papers by day. x-noneState purpose of each trip x-noneIf direct billed put DB1, DB2, etc x-noneEnter start and stop points for each trip Amount x-noneNebraska Supreme Court Administrative Office of the Courts and Probation x-noneEXPENSE REIMBURSEMENT REQUEST x-noneNAME OF PLACE AND NATURE OF SERVICE x-noneTRAVEL TIMES x-nonePERSONAL VEHICLE x-noneMEALS MISCELLANEOUS American LegalNet, Inc. www.FormsWorkFlow.com DateLocationBreakfastLunch Dinner1)Lunch for 1-day travel is not reimbursable.2)Breakfast maybe reimbursed if departure is before 6:30 am or 1.5 hours before the employee begins work, whichever is earlier.3)Lunch maybe reimbursed if, for overnight travel, departure is at or before 11 am or the return time is at or after 2 pm.4)Dinner mayber reimbursed if the return time is after 7 pm or 2 hours after the employee's workday ends, whichever is later. 5) Meal expenses incurred in the city or town in which the residence or primary work location of such employee is located are not reimbursable. Meal Receipt Form - Please attach your meal receipts by day American LegalNet, Inc. www.FormsWorkFlow.com