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160401 R55CKS2 LOGISBOI CITY OF NEW HOPE 2/25/2015 11:11:18 Note: Check Amount may not reflect actaul check total due to sequence of data Council Check Summary Page- 32 2/25/2015 - 2/25/2015 Check# Date Amount Supplier/Explanation (W�WPO# Doc No Inv No BU Obj Sub Subledger Account Description BU Description Cc Dept Div * 1 6 0 4 0 1 * * 1 0 2 9 7 8 * * 2 - 2 S - 2 0 1 S * X ME19M HE * L O S E R / L R N T H 0 N Y * 160401 212512016 102918 LOSER, ANTHONY 32.18 Flash drive/usb 83928 REIMS021915 0185 6290 Supply/Othr Oprntg Police-Administration 09001 014 32.18 A Expense Reimbursement Form NAME: (please print) i8nl�o"`f lOW,- � ' .� ; , Business Mileage Trip Other Date Purpose Start End Miles Parking Description Amount Total Miles: x$.555 pp TOTALS: =$ $ $ *Receipts are required for all expenses, except mileage. I hereby request payment in the amount of $'e 2" 1 for expenses incurred between �` ����� and . Mileage was incurred while using my personal car on city of New Hope business. Receipts for purchases are attached. 1 certify by my signature below that this is a just and correct claim and that no part of it has been paid. SIGNATURE: DATE: DEPARTMENT HEAD A(UTHORIZATTION: - Zl Account number: �� Amount: 3 2 e j ECEOVE Account number: Amount: Account number: Amount: FEB 2015 Account number: Amount: G:\City Manager\FORMSTersonnelklExpense Reimb,doc W005;rev 11/2005;rev 1-2006,rev 1-2007',rev 1-2000',rev 7 12008,rev12/22/O8 for 2009,rev.12/28/09 for 2010;rev 12120/10 for 2011;rev for July 1,2011 wm #05682 4200 WINNETKA AVE N #05882 4200 WINNETKA AVE N NEW HOPE MH 55428 NEW HOPE, MN 55428 763-545-6466 763-545-6466 289 1298 0022 02/19/2015 '12:34 PM 330 7976 0021 02/18/2015 10:49 AM RETURN I'1EM WALG EASYSTORE USB FLASH DRV 16 WALG FLSH DRV 16GB 51007465313 A 9.99 ALE 61007465313 A -9.99 RET REGULAR PRICE 29.99 REWARDS SAVINGS 20.00 USB 32GB HIGH SPEED 2.0 DRV BLACK RETURN VALUE 9.99 84993300165 A 29.99 SUBTOTAL RETURN VALUE 29.99 SALES TAX A=7.275% 0.73 SUBTOTAL 20.00 TOTAL . TAX A=7,275% 1 .46 1072 VIJA ACCT 10,72 TOTAL 21 ,46 CHANGE .00 VISA ACCT 21 .46 BALANCE: REWARDS SAVINGS 20.00 CHANGE DO THANK YOU FOR SHOPPING AT WALGREENS THANK YOU FOR SHOPPING AT WALGREENS WITH BALANCE REWARDS YOU CAN SAVE WITH BALANCE REWARDS YOU CAN SAVE ON THE THINGS YOU NEED AND TREAT ON THE THINGS YOU WEED AND TREAT YOURSELF TO THE THINGS YOU WANT. YOURSELF TO THE THINGS "OU WANT, RESTRICTIONS APPLY, SEE PROGRAM RESTRICTIONS APPLY, SEE PROGRAM RULES FOR DETAILS. PLEASE GO RULES FOR DETAILS. PLEASE GO TO WALGREENS.COM/BALANCE. TO WALGREENS.COM/BALANCE:. MW nCOO 7017 mc,_,Cn21RnQ RF�lit nuja_o0»1_')(IPA F09-1903 II ii