HomeMy WebLinkAboutGrant Related - Health DistrictGRANT COUNTY C _ MPLETED
BOARD OF COUNTY COMMISSIONERST3Y: ;odt
To: Board of County Commissioners
Date July 21, 2020
Re: CRF Reimbursement Request #10
Reimbursement No. 10 on Coronavirus Relief Funds (CRF) CARES Act Grant for the
Health District for the period July 1, 2020 through July 15, 2020, with the Department of
Commerce in the amount of $97,226.15..
County Review Conducted By:
'1
rittany Rang, Admihistrative Scifvices Coordinator
BOARD OF COUNTY COMMISSIONERS
GRANT COUNTY WASHINGTON
Cindy Carter, thair
Tom Taylor, Vice Chair
Richard Stevens, Member
l Vic"
Date:
—
Date:
Comnavirus Relief Fund
A-19 Activity Report
Report Period: I Jul 1-15 2020
Expenditures
1 Medical Expenses
A. Public hospitals, clinics, and similar facilities
Previously
Reported Expenditures
Expenditures this
5 $
Current
Cumulative
Invoice Expenditures
$
Total
DescriptionEligible
Brief
B. Temporary public medical facilities &increased capacity
$ $
- $
.....................................................................................................................
C. COVID-19testing,.induding serological testin&............................... _...... _.
$ - $
D.Emergency medical. response ezpenses.........................................................
$ _ $
_ $
_
E. Telemedicine capabilities
.................._.__..._.............._............._....._.............__........_�...
$ - 5
- $
-
F. Other:
Sub -Total:
2 Public Health Expenses
A. Communication and enforcement_of public health measures
$ 5
$ - $
S
- $
-
.........................................................................
B. Medical and protective supplies, including sanitation, and PPE
$ - $
C. Disinfecting. public areas and other facilities
$ - $
D. Technical assistance on COVID-19 threat mitigation
$ - $
E. Public safety measures undertaken
d...............................................
5 $
_ $
-
..........................................................
F. Quarantining individuals
$ $
$
-
......_............_.._.............................................__....................._......___........_...
G. Other:
$ 5
$
Sub -Total:
3 Payroll expenses for public employees dedicated to COVID-19
A. Public Safety
$ $
$ - $
S
-
B. Pubiic Health
$ $
-C.
91,478.13
Pa roll, Benefits, indirect
....................._................................................................__.........................
Health Care
-
$ $
-D.
....................................__......................................._...........................
HumanServices
$ $E.
M$9911417813
Economic Development
_
$ $
......................—_......._....._......................._....._...."'.....
F.
$ $
Sub -Total:
4 Expenses to facilitate compliance with COVID-19-measures
A. Food access and delivery to residents
$ $
$ $
91,478.13
$
B. Distance learning tied.to school closings _
$ - $
- $
-
C. Telework capabilities of public.employees
............. .
$ - $
2,732.62 $
2,732.62 keyboards, mouses, laptop bags, hones and hone bill, mileage
D. Paid sick and paid familyand_medical, leave to public employees
................... . ......................
$ - $
- S
E. COVI0.19-related expenses in countyjails
$ - $
- $
-
F. Care and mit anon services for, homeless populations
........................... ...____....
$ - $
- $
-
G. Other_ Postage
$ $
315.40 $
315.40 Posta efor June
Sub -Total:
5 Economic Supports
A. Small
..............B.usinessGran.tsfobusinesinterrupti
.............. .s o
$ $
$ $
3,048.02 $
3,048.02
B. Payroll.Sup�ort Programs _ ______
$ - $
- S
C. Other:
$ $
$
Sub -Total:
6 OtherCOVID-19 Expenses .................
$ $
$
A. Other: CYiftonLarsonAllen
$ $
"
1,500.00 $
1,500.00 Accounting Services
..........................._._._...................................._.............._.__._..............._.._..................
B. Other: Katherine Kenison
$ $
'
1,200.00 $
1,200.00 Legal Services
.....................___._.._._..._.....,......_.W......_......._._........._._....................
C. Other:
$ $
$
D. Other:$
- $
$
_
E. her :................ .................................................... .................... ...................................
.-----
Ot
5 5
_ $
... -----
Sub -Total:
$ $
2 700.00 $
2,700.00
1oft
Company Na Grant County Health District
Report Name General Ledger Report
Reporting Sc ACCRUAL
Start Date: 7/1/2020
End Data: 7/15/2020
Location:
Program` 9500—Novel Corona Virus
Posted Dt. Doc DL Dot Memo / Description
vendor Name
Program Name
2ML
Dealt
floc.
5004000 - Indirect cost rate (Balance Forward As of 07/01/2020)
7/15/2020 7/15/2020 PPE 7/15/20 Indirect Allocation
COVID Technology
GJ
111.97
7/15/2020 7/15/2020 PPE 7/15/20 Indirect Allocation
COVID Business
GJ
268.71
7/15/2020 7/15/2020 PPE 7/15/20 Indirect Allocation
COVID Emergency Preparednes
GJ
6,670.98
7/15/2020 7/15/2020 PPE 7/15/20 Indirect Allocation
COVID Disease Investigation
Cil
21,558.65
Totals for 5004000 - Indirect cost rate
28,610.31
5101010 - Salaries (Balance Forward As of 07/01/2020)
7/15/2020 7/15/2020 PPE 7/15/20 Salaries
COVID Technology
PYR7
165.93
7/15/2020 7/15/2020 PPE 7/15/20 Salaries
COVID Business
PYRI
422.89
7/15/2020 7/15/2020 PPE 7/15/20 Salaries
COVID Emergency Preparednes
PYRJ
10,818.82
7/15/2020 7/15/2020 PPE 7/15/20 Salanes
COVID Disease Investigation
PYRI
34,562.05
Totals for 5101010 - Salaries
45,969.69
5101020 - Benefits (Balance Forward As of 07/01/2020)
7/15/2020 7/15/2020 PPE 7/15/20 Benefits
COVID Technology
PYRJ
79.73
7/15/2020 7/15/2020 PPE 7/15/20 Benefits
COVID Business
PYR1
166.88
7/15/2020 7/15/2020 PPE 7/15/20 Benefits
COVID Emergency Preparednes
PYRJ
3,825.12
7/15/2020 7/15/2020 PPE 7/15/20 Benefits
COVID Disease Investigation
PYRI
12,826.40
Totals for 5101020 - Benefits
16,898.13
5103031 - Office supplies (Balance Forward As of 07/01/2020)
7/9/2020 7/9/2020 125192 Bill - Staples Credit Plan: June 2020 Statement
Staples Credit Plan
COVID Technology
APIA
286.11
a
Totals for 5103031 - Office supplies
286.11
5103038 - Small tools (Salance Forward As of 07/01/2020)
7/9/2020 7/9/2020 125192 Bill - Staples Credit Plan: June 2020 Statement
Staples Credit Plan
COVID Technology
APJA
216.78
b
Totals for 5103038 - Small tools
216.78
5104041 - Professional semlcas (Balance Forward As of 07/01/2020)
7/1/2020 7/1/2020 125193 Bill - GiRonLarsonAllen LLP: May and June 2020 Services
CliRonLarsonAllen LLP
COVID Business
APIA
1,500.00
C
7/1/2020 7/1/2020 125184 Bill - Kenison, Katherine: June Legal Services
Kenison, Katherine
COVID Business
APJA
1,200.00
d
Totals for 5104041 - Professional services
2,700.00
5104046 - Communication (Balance Forward As of 07/01/2020)
7/1/2020 7/1/2020 125190 Bill - Verizon Wireless: June 08 - July 07, 2020
Verizon Wireless
COVID Technology
APIA
2,016.98
e
7/1/2020 7/1/2020 125357 Bill - Pitney Soaves: lure 2020 Postage
Pitney Bovres
COVID Disease Investigation
APIA
315.40
f
Totals for 5104046 - Communication
2,332.38
5104140 - Travel (Balance Forward As of 07/01/2020)
7/1/2020 7/1/2020 125178 BIII - Castro, Maria: Mileage reimbursement for April, May, June
and July
Castro, Mans
COVID Disease investigation
APJA
158.70
9.
Totals for 5104140 - Travel
158.70
5104141 - Meals A. Mileage (Balance Forward As of 07/01/2020)
7/9/2020 7/9/2020 125179 Bill - Amie Pruneda: Mileage Reimbursement
Amie Pmneda
COVID Disease investigation
APIA
54.05
h
Totals for 5104141 - Maela & Mileage
54.OS
Grand Total 97,226.16
F,
Staples -
815N. Stratford Rd Suite B Ref: a.
Staples
Moses Lake, WA 98837
(509) 765-4600
SALE 1950103 1 001 62226
815 N. Stratford Rd Suite 8
1301 06/29/20 12:09
Moses Lake, WA 98837
Q'f Y SKU PR T C E
(509) 765-4600
RETURN 1950103 1 001 62227
REWARDS NUMBER 2590128001
1301 06/29/20 12:11
1 WENGER COMET/MAINE
QTY S K U P R T C E
674204041949 69.99
1 WENGER COMET/MAINE
REWARDS NUMBER 259(1128rNil
674204041949 69.99
START RETURNF��r��*
1 SWISS SATURN MESSE
Original transaction information:
092837748842 69.99
REG: 1 TRANS: 62226
1 SWISS SATURN MESSE
DATE: 06/29/20 STORE: 1301
092831/48842 69.9
1 SWISS SATURN MESSE
1 LOGITECH M310 WRLS
09283/748842 -69.99
097855066237 11.99
END RETURN
1 LOGITECH M310 MSE
SUBTOTAL. -69.99
097855076540 11.99
Standard Tax 8.40% -5.88
1 LOGITECH M310 MSE
IDIAL $-75.87
097855016540 17.99
SUBTOTAL 333.93
Staples Charge USD$ -75.87
Standard Tax 8.40% 28.05
Card No.: XXXXXXXXXXXX0388 (S)
TOTAL $361.98
Auth No.: 182787
PO No.:supplies
Staples Charge USII$361.98
Card No.: XXXXXXXXXXXX0388 (SJ
Tp'TAI.. T TEM;a U
Atith No.: 029557
PO No.:supplies
TUI -AL.. T.TEMS 7
TRU RED
Business essentials designed
thoughtfully to work beautifully.
TRU RED
Shop Smarter. Get Ruwarded.
Business essentials designed
Staples Rewards members get up to 5%
thoughtfully to work beautifully.
back in Rewards in store only.
Exclusions Apply. See an associate for
Shap Smarter. Get Rewarded.
full program details or to enroll.
Staples Rewards members get tip to 5%
back in Rewards in store only.
THANK YOU FOR SHOPPING AT STAPLES!
Exclusions Apply. See an associate for
full program details or to enroll.
E -Cycle Washington: Free, Easy,
Responsible Recycling for Computers,
[HANK YOU FOR SHOPPING AT STAPLES!
Monitors and TVs www.ecyclewashinutan.org
1 -800 -Recycle
E -Cycle Washington: Free, Easy,
Responsible Recycling for Computers,
Monitors and TVs www.ecyclewashingtnn.ore
I I I
II IIIIII�I�III�I�iI�l+�l� (IIIIIIIII�III�II�I�I�I�II�II� I � I
1 -800 -Recycle
1 3 0 1 0 f, 2 1 2 0 6 2 2 2 7 0 1
I! iiiliilllllllllilillli!'1111I1111�IItil'11f11{NI!1111! f SII
I ill 1 it I.
Staples.
815 N. Stratford Rd Suite 8
14ose3 Lake, WA 98837
(509) 755-4600
SALE 1900947 1 001 40285
1301 06/18/20 02:09
QTY 1c;KLi PRICE
REWARDS NUMBER 2590128001
1 STAPES INVSBL TAP *
718103094665
7J 2.00
1 STABLES ,1MB PPR C(.
718103047500
� ' 0,99
1 SIAPLES INVSBL TAP $
718103094665
Ql 12.00
1 SPLS BOND ROLL 2 1
718103241687
13.49
1 STICKIES 3X3 POP R
718103113410
18.99
1 STICKIES 3X3 POP R
718103294256
l i 18.99
1 AGER RY241Y 24 FHD
193199102188
119.99
Instant Savings <-2. O>
Price Override 99.9
a o,n -20.00
1 AGER RY241Y 24 FI -11)
193199102.168
119.99
Instant Savings <
Price Override 99.9
Cot/((:L -20.00
SUBTOTAL
286.44
Standard Tax 8.40%
24.06
TOTAL
$310,50
Staples Charge
USD$310.50.
Card No.: XXXXXXXXXXXX0388 [S]
Aulh No.: 1181i7U
110 No.
Ref: b.
it 1Al .I. 'IakM t:
�I lam is
cul 1e11L ly un PI 0(110 iou. Sume
coupons are only valid on regular priced
items. Please see Coupon Terms and
conditions for details.
TRU RED
Business essentials designed
thoughtfully to work beautifully.
Shop Smarter, Get Rewarded.
Staples Rewards members get up to 5%
back in Rewards in store only.
Exclusions Apply. See an associate for
full program details or to enroll.
THANK YOU FOR SHOPPING AT STAPLES!
E -cycle Washington,, Free, Easy,
Responsible Recycling for Computers,
Monitors and TVs www.ecyclewashington.org
1 -800 -Recycle
G'IIIVYI0IIIIp1191�IIIVMIUIIIII�III!IIIIII�IY
0
Grant County Health District
1038 W. Ivy, Suite 1
Moses Lake, WA 98837
June Accounting Services
May Financial Statements
Annual 2019 Financial Statements - Bill No. 2
Monthly Service Fees
Monthly Intacct Service Fee
Additional COVID expenses. Budgeting, analysis, billing.
MAC COVID Fiscal Training
MAC Billing
ConCon Billing
Snap Ed Billing
Direct Billing Inquiries to
CliftonLarsonAllen LLP
1202 N. 16th Avenue
Suite 100
Yakima, WA 98902
(509) 823-2910
Account Number 087-401628
Invoice Date 7/20/2020
Invoice # 2554767
Authorization Number 0001272347
Ref: c.
Technology and Client Support Fee
$332.68
750.00
4,000.00
207.32
160.00
1,500.00
255.00
185.00
175.00
35.00
$361.63
Invoice Total $7,961.63
We Appreciate Your Business and Referrals
Payment is due upon receipt.
CliftonLarsonAllen LLP PO Box 31001-2443 Pasadena, CA 91110.2443 (509) 823-2910
Please detach and remit payment to the
address below.
CliftonLarsonAllen LLP
PO Box 31001-2443
Pasadena, CA 91110-2443 Amount Remitted $
Account Number 087-401628
To pay your bill electronically please visit Invoice Number 2554767
clacon nect.com/bil 1pav
Grant Garry Health Dislricl
025970
036555
1��I�IK
KENisoNFRANZ
ATTORNEYS AT LAVs'
KATHERINE L. KENISON, PS ANNA C. FRANZ, PS
Grant County Health District
1038 W Ivy
Moses Lake, WA 98837
July 1, 2020
DATE
DESCRIPTION OF CHARGES
HOURS
06/02/20
Review/send email correspondence staff
0.3
06/05/20
Review/send email correspondence staff
0.3
06/08/20
Review/send email correspondence staff
0.3
06/10/20
Review agenda; Board Meeting
2.0
06/11/20
Review/send email correspondence staff; PC staff; PC Prosecutor
1.0
06/12/20
PC staff; review PRR's emails; email Prosecutor
0.8
06/15/20
Review/send email correspondence re PRR's
0.3
06/17/20
Review/send email correspondence re PRR's
0.4
06/18/20
Review/send email correspondence staff
0.2
06/18/20
Email 5 day form
0.2
06/19/20
Review Health Officer Order
0.7
06/19/20
PC Prosecutor; review/send email correspondence staff x2
0.8
06/23/20
Review/send email correspondence staff
0.3
06/24/20
Review/send email correspondence staff
0.2
06/30/20
Email re NWJ PRR
0_2
TOTAL
Ref: d.
8.0
Previous Balance 3,320.00
Received On Account (3,320.00)
Current Fees 1,600.00
Costs .00
Total $ 1,600.00
This statement may not include services or expense Items for which we have not yet been billed or have not yet been posted to your account.
Our statements are immediately due and payable on receipt. Finance charges of 1% per month (annual percentage rate of 12%) will be charged
to your account if not paid within thirty days of the billing date unless other arrangements have previously been made.
Verizon Bill Vendor #: VERIZW
Description
Name
Amount
11 418 33
34 39 141 33 447 413 416 424 429AFIX 440 53 54
80
56P 56T A -em
39 9502 CVT
Variance
509-237-0710
Cyndi Cantu
$
58-80
$
58.80
0.00
509-237-2159
Claire
S
58.80 S
14.70
5
44.10
0.00
509-237-2165
Mary
$
SS.SO $
14.70
$
44.10
0.00
509-237-2436
Maria Mifi
$
40.01
$
40.01
0-00
509-350.3814 Julia Austin
$
58.80
$
58.80
0.00
509-350-3897
1 Food Program Will
$
40.01
$
40.01
0.00
509 398-2083
124hrphone
$
31.47
$
31-47
0.00
509 398-7628
Amber
$
58.80
5.88 5.88
$
47.04
0.00
509 398-7629
Daniel
$
58.80
44-10
$
14.70
0.00
509 398.7662
Darcy
$
58.80
$
58.80
0.00
509 398-7712
Vicky
$
58.80
$
58.80
0.00
509 398-7761
Stephanie MIFI
$
40.01
$
40.01
0-00,
509 431-2092
Food Program Mifi
$
40.01
$
40.01
0.00
509 750-0481
Heather
$
58.80
5
58.80
0.00
509-750-0996
Laina Mitchell
S
58.80
$
58.80
0.00
$09 750.4863
Ben Glosenger
$
58.80
14.70
$
44.10
0.00
509 750-6549
Tom
5
58.80
44.10
$
14.70
0.00
509-760-5013
Vicky Mi Ft
$
40.07
20.04
$
20.04
0.00
509 760-9580
Maria
$
58.80
$
S8.80
0.00
509-766-7960
Grant Co Health
District
$
25.29
$
25.29
0.00
509 793-3360
Kelsey
$
58.80
$
58.80
0.00
509 793-3520
Theresa, VBG - 2
$
188.88
$
188.88
0.00
509 793-4406
Stephanie S
5
58.80
$
58-80
0.00
509 793-5537
Rita
$
58.80
$
58-80
0.00
509855-2782
Theresa (MIFI)
5
40.01
$
40.01
0.00
509 906-0047
Amie
$
58.80
$
58.80
0.00
509 906-0087
Ashly
5
58.80
29.40
$
29.40
0.00
S09-906.0091
Reece
$
58.80
11.76
5
47.04
0.00
509-906-0179
GCHD
$
25.29
$
25.29
0.00
509-906.0189
VR New
$
40.01
$
40.01
0.00
509-906-0211
GCHD
$
25.29
$
25.29
0-00
509-906-0212
GCHD
$
25.29
$
25.29
0.00
509-906-0357
GCHD
$
25.29
$
25.29
0.00
509-906-0400
VR New
$
40.01
$
40.01
0.00
509 906.0673
Reina
$
58.80
14.70
$
44.10
0.00
509-989-5795
Dr. Brzezny (Miff)
S
40.01
5
40.01
0.00
509-906-6010
25 lines @$32.02
$
800.50
800.501
0.00
509-906.6028
New Desk Phone
$
71.55
$
71.55
0.00
509-906-6029
Epik Connection
$
27.32
$
2732
0.00
509-906-6039
New Desk Phone
$
71.55
$
71.55
0.00
509-906.6117
New Desk Phone
$
71.55
$
71.55
0.00
509-906-6254
New Desk Phone
$
71.55
$
71.55
0.00
509-906-6350
Cynthia Razo
$
40.46
$
40.46
0.00
S
3.037.43 S
829.90 $ 20.04 $ -
$ • $ • $ - $ - $ 14.70 $ - $ • $ - $ - $ - $ • $ 132.30
S 17.64 S 5.88 $ -
S- S
2,016.98
0.00
Cpmromlcstions - 4046 v
800.5 ��/
pitney bowel (41,
Account Summary Report
Date Range: May 30 2020 to Jun 29 2020
Meter Group: Custom
Meter 7H00-1282782 at GRANT COUNTY HEALTH DIST,MOSES LAKE,WA,USA
Account Summary
Aaount Sub Account Sub Sub Account Pl ces1 Total Charged
--------1 --- —
ADMIN
c6
$1.000
$3.300
2
Sub Total
6
$3.300
$1.000
Total
6
$3.300
Food
11
$13.6001
$67.450
Sub Total
11
$13.600
Total
11
$13.600
PHEPR
510
$315.400
Sub Total
510
$315.400
Total
530
$315.400
STI
9 ;
$4.500
Sub Total
9
$4.500
Total
9
$4.500
Septic
29
$20.950
I
Sub Total
29
$20.950
Total
29
$20.950
Solid Waste
2
$1.000
Sub Total
2
$1.000
Total
2
$1.000
Vital Records
I -
124
$67.450
Sub Total
124
$67.450
Total
124
$67.450
Water _.1 _ 3 $2.400
Sub Total 3 $2.400
i' Total 3 $2.400
Grand Total 694 $428.600
Ref: f.
A 1038 West Ivy, Suite 1
-A �+ Moses Lake, WA 98837
W
GCHD
GRANT COUNTY HEALTH DISTRICT
2020 Expense Reimbursement Request
Name: '10
Date
Travel Status
Start/End
Meals
Lodging
Personal
Vehicle #
of Miles
Other
Expenses
(Receipts
required.)
Location, Purpose, Details of Other Expenses
Program
Code
12131120
5:30 AM
9:00 PM
B 13.00
#
440
25.00
Wenatchee, WA Washington State Public Health
Association Annual Meeting. $25 Parking.
11
L 14,00
$
253
D 23.00
04/16/20
11:30 AM
12:OOPM
B
#
21
Ephrata, Command Post traveled back to Moses Lake
Office
442
L
$
12.08
D
05/13/20
8:00 AM
1 9:10 AM
B
#
11
Chelan Douglas Health District, East Wentachee, delivered
Covid-19 test kits
442
L
$
6.33
D
05/13/20
9:30 AM
10:45 AM
B
#
66
Returned to Grant County Health District, Moses Lake
from East Wentachee, delivered Covid-19 Test Kits
442
L
$
37.95
D
06/20/20
8:30 AM
9:15 AM
B
#
36
Quincy to Mose Lake Office to work on Covid-19 Letters
442
L
$
1 20.70
D
06/20/20
5:00 PM
5:45 PM
B
#
36
Moses Lake Office to Quincy from working on Covid-19
Letters
442
L
$
20.70
D
07/04/20
1:30 AM
2:30 AM
B
#
53
Vantage to Moses Lake Office to work on Covid-19 Letters.
442
L
$
30.48
D
07/04/2.0
5:00 PM
6:00 PM
B
#
53
Moses Lake Office to Vantage from working on Covid-19
Letters.
442
L
$
30.48
D
B
#
L
$
0.00
D
B
#
Ref: g.
I
$
0.00
D
B
#
L
S
0.00
D
B
#
L
$
0.00
D
B
#
L
$
0.00
D
$0.00
$0.00
$0.00
Total (Mileage @ 0.575 $158.70
GSA Per Diem Schedule:
Employee Signature:
Total Reimbursement Request 158.70 1
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Date:
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Supervisor Signature: �ti��� ( � Date:
G C H D
GRANT COUNTY HEALTH DISTRICT
1038 West Ivy, Suite 1
Moses Lake, WA 98837
2020 Expense Reimbursement Request
Name: Amalia Pruneda
Date
Travel Status
Start/End
Meals
Lodging
Personal
Vehicle #
of Miles
Other
Expenses
(Receipts
required.)
Location, Purpose, Details of Other Expenses
ram Pro
g
Code
12131120
5:30 AM
9:00 PM
6 13.00
#
440
25.00 lAssociation.Annual
Wenatchee, WA Washington State Public Health
Meeting. $25 Parking.
11
L 14.OQ
$
253
D 23.00
04/15/20
8:00am
8:20am
B
#
21
From GCHD to Courthouse in Ephrata
442
L
$
12.08
D
04/15/20
4:40pm
5:00pm
B
#
21
From Courthouse in Ephrata to GCHD
442
L
$
12.08
D
06/28/20
7:30am
8:00am
B
#
26
(On -Call work) From Othello to GCHD
442
L
$
14.95
D
06/28/20
4:30pm
5:00pm
B
#
26
(On -Call work) From GCHD to Othello
442
L
$
14.95
D
B
#
L
$
0.00
D
B
#
Ref- h.
L
$
1 0.00
D
B
#
L
$
0.00
D
B
#
L
$
0.00
D
B
#
L
D
B
#
L
D
B
#
L
$
0.00
D
B
#
L
$
1 0.00
D
$0.00
$0.001
$0.00
Total Mileage @ 0.575 $54.05
GSA Per Diem Schedule:
Employee Signature:
Supervisor Signature:
Total Reimbursement Request �-$54.05
https•//www gsa gov/travel/plan-book/per-diem-rates/per-diem-rates-lool<up/?action=perd