STATE OF VERMONT PERSONAL EXPENSE CLAIM NameTown of ResidenceDepartment/Board or CommissionAddress Position TitleSocial Security No. Break-ExplanationDatefastTotalLunchDinnerOtherLodgingI certify under the pains and penalties of perjury, that the foregoing is a correct statement of the time actually spent, mileage actually and constructivelytraveled, and amounts necessarily incurred or paid by me in the discharge of my duties. (32 V.S.A. 464) AAF6AClaimant's SignatureDateSupervisors ApprovalDate () FINANCE & MANAGEMENTGRANDTOTAL TravelMilesAmount American LegalNet, Inc. www.FormsWorkFlow.com