Monthly claim form

Name:

Overseas / Outstation Claims

Date
Description Value in foreign Currency rate Accommodation Daily allowance Transportation Customer
(DD/MM/YY) Currency Travel (RM)
currency used (RM) (RM) (RM) entertainment (RM)
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
TOTAL 0.00 0.00 0.00 0.00 0.00

I hereby certify that all expenditures have been made for the benefit of Wincor Nixdorf and that I have not been reimbursed previously for any items listed

Signature of employee Approved by supervisor Checked by HR Approved by MD

Date Date Date Date

Page 1 of 11
 Total
Misc

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00

0.00

d by MD

te

Page 2 of 11
Monthly claim form

Name: R.SUMITHRAN
PAGE 1
Travel claim

Incomplete indicator (I or C)

Service Order/Report No.

RM2.00 per service call

Receipt no
From site
Date (DD/MM/YY) Description

To site
6 SON MECICAL CLAIM
6
6
02/05/18 3 MBB PULAU KETAM 54019746
6
03/05/18 4 RHB BANGSAR SAUTH 54108592
02/05/28 2 SCB LAMAN SERI 54083865
6
6
6
6
6
6
6
6
6

Page 3 of 11
 Monthly claim form

PAGE 1

Date (DD/MM/YY)
Name: R.SUMITHRAN

Description

Page 4 of 11
Incomplete indicator (I or C)

Service Order/Report No.

From site

To site

Receipt no

RM2.00 per service call

Travel claim
Monthly claim form

Name: R.SUMITHRAN
PAGE 1
Travel claim

Incomplete indicator (I or C)

Service Order/Report No.

RM2.00 per service call

Receipt no
From site
Date (DD/MM/YY) Description

To site
TOTAL

Signature of employee Approved by supervisor

Date Date

Page 5 of 11
 KM based on distance table (KM)

vel claim
Total Km to claim (less 80KM) (KM)

For 1st 80 km (RM0.50 per km) (RM)

Balance after 1st 80 km (KM)

For balance km (RM0.35 per km)

(RM)

Taxi

Petrol

50.00
40.00
80.00
50.00
60.00
Toll Touch n Go

18.00
Parking

2.00
4.00
4.00

Medical
60.00

Medical Check-up

Page 6 of 11
Road tax (if entitled)

Car insurance (if entitled)

Car maintenance (if entitled)

Customer entertainment

Customer gifts / Misc

Telephone bill (overseas call only)

From week date

Standby allowance
 KM based on distance table (KM)

vel claim
Total Km to claim (less 80KM) (KM)

For 1st 80 km (RM0.50 per km) (RM)

Balance after 1st 80 km (KM)

For balance km (RM0.35 per km)

(RM)

Taxi

Petrol

Toll Touch n Go

Parking

Medical

Medical Check-up

Page 7 of 11
Road tax (if entitled)

Car insurance (if entitled)

Car maintenance (if entitled)

Customer entertainment

Customer gifts / Misc

Telephone bill (overseas call only)

From week date

Standby allowance
 KM based on distance table (KM)

vel claim
Total Km to claim (less 80KM) (KM)

For 1st 80 km (RM0.50 per km) (RM)

0.00
Balance after 1st 80 km (KM)

For balance km (RM0.35 per km)

(RM)

0.00
Taxi

0.00

Date
Petrol

Checked by HR
280.00
Toll Touch n Go

18.00
10.00 Parking

Medical

Medical Check-up
60.00 0.00

Page 8 of 11
Road tax (if entitled)
0.00

Date

Car insurance (if entitled)

Approved by MD
0.00

Car maintenance (if entitled)

0.00

Customer entertainment
0.00

Customer gifts / Misc

0.00

Telephone bill (overseas call only)

0.00

From week date

Standby allowance

I hereby certify that all expenditures have been made for the benefit of Wincor Nixdorf and that I have not bee
tandby allowance Inconvenience allowance Meal allowance

East or West Malaysia (E / W)

Accomodation
Public Holiday (PH)

Breakfast (RM15)

Total allowance
Dinner (RM20)
Lunch (RM15)
To week date

Total hours
Allowance

Allowance
From time

From time

Misc
Total
To time

To time
0:00 0.00 0.00 0.00 0.00 0.00 60.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 22.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 4.00
0:00 0.00 0.00 0.00 0.00 0.00 2.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 60.00
0:00 0.00 0.00 0.00 0.00 0.00 50.00
0:00 0.00 0.00 0.00 0.00 0.00 80.00
0:00 0.00 0.00 0.00 0.00 0.00 40.00
0:00 0.00 0.00 0.00 0.00 0.00 50.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00

Page 9 of 11
tandby allowance Inconvenience allowance Meal allowance

East or West Malaysia (E / W)

Accomodation
Public Holiday (PH)

Breakfast (RM15)

Total allowance
Dinner (RM20)
Lunch (RM15)
To week date

Total hours
Allowance

Allowance
From time

From time

Misc
Total
To time

To time
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00

Page 10 of 11
tandby allowance Inconvenience allowance Meal allowance

East or West Malaysia (E / W)

Accomodation
Public Holiday (PH)

Breakfast (RM15)

Total allowance
Dinner (RM20)
Lunch (RM15)
To week date

Total hours
Allowance

Allowance
From time

From time

Misc
Total
To time

To time
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0:00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 368.00
Less Cash advance
= Net due to me 368.00

and that I have not been reimbursed previously for any items listed

Page 11 of 11