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Conferences

Description	Amount	Actions

There are no Items.

Conferences Subtotal

Amount: $0.00

Tolls

Total Mileage

* Rate

Mileage Reimbursement

Amount: $0.00

Meals

Description	Amount	Actions

There are no Items.

Meals Subtotal

Amount: $0.00

Dues, Journals, Licenses, Subscriptions, Books

Description	Amount	Actions

There are no Items.

Dues, Journals, Licenses, Subscriptions and Books Subtotal

Amount: $0.00

Cellular phone, Fax line, Internet, Pager

Description	Amount	Actions

There are no Items.

Cellular, Fax, Internet and Pager Subtotal

Amount: $0.00

Business Expense Reimbursement

Description	Amount	Actions

There are no Items.

Business Expense Reimbursement Subtotal

Amount: $0.00

Computers, Equipment, Service and Supplies

Description	Amount	Actions

There are no Items.

Computers, Equipment, Service and Supplies Subtotal

Amount: $0.00

Miscellaneous

Description	Amount	Actions

There are no Items.

Miscellaneous Subtotal

Amount: $0.00

Confirmation

Related Receipts

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“Nurse Anesthesia of Maine expects that the primary use of the item you’ve requested reimbursement for is business use in accordance with IRS guidelines.”

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Grand Total

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I certify that all expenses submitted with this claim form were incurred while I was covered by the Professional Reimbursement Benefit Plan. I understand that I am solely responsible for the sufficiency, accuracy and veracity of all information relating to this claim. I understand that should the expenses submitted with this claim form subsequently be determined by the IRS to be ineligible as a business expense. I may be liable for the payment of all related taxes, including Federal, State or Local Income Tax which relate to such expense.

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Professional Reimbursement Request

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