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City f Georgetown
City Council Member Statement of Expenses or Lost lncoihe 4_ W
Council Member's Name:
'i
For the month of .Ice & 20 f0 , I hereby certify that I have the
following expenses and/or lost income related to exercising my duties as a Council member.
E7CPENSES9
Please fill out sections a - d below and check taxable or non-taxable.
(a.) Phone expenses:
(b.)1 ... miles at I.R.S. rate: $.50 per mile
(c.) Home office expense for area set aside for City business:
$ -
$ El FAI
$ 0
(d.) Other expenses - Please itemize below:
$ E-1 0
$ 0 F-1**
$ E-1 CQ**
"These items can be reimbursed non-taxable per IRS guidelines when detailed receipts or mileage
reports are attached to this form.
!E. LOST INCOME
(e.) Hourly rate X hours spent = Lost Income
X = 0.00 $ 0.00
Ill, TOTAL REIMBURSEMENT $ 0.00
In no case can the amount of reimbursement exceed $800 per month.
Signed on the t day of k=y V" 20 �.
signature
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x
X
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$ -
$ El FAI
$ 0
(d.) Other expenses - Please itemize below:
$ E-1 0
$ 0 F-1**
$ E-1 CQ**
"These items can be reimbursed non-taxable per IRS guidelines when detailed receipts or mileage
reports are attached to this form.
!E. LOST INCOME
(e.) Hourly rate X hours spent = Lost Income
X = 0.00 $ 0.00
Ill, TOTAL REIMBURSEMENT $ 0.00
In no case can the amount of reimbursement exceed $800 per month.
Signed on the t day of k=y V" 20 �.
signature