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THE NAVAJO NATION FINANCIAL SERVICES DEPARTMENT DATE OF CLAIM ACCOUNTS PAYABLE USE ONLY AB GENERAL CLAIM FORM NAME OF CLAIMANT PRINTED SOCIAL SECURITY NUMBER MAILING ADDRESS CO CITY STATE ZIP CODE COUNCILMEN ONLY --- CHECK ONE OF THE FOLLOWING BOARD OF ELECTION NAVAJO UTAH COMMISSION TELECOMMUNICATION REG. COM ROUGH ROCK CHAPTER LABOR COMMISSION NN WATER RIGHTS COMMISSION GOVERNMENT DEVELOPMENT SHIPROCK CHAPTER HUMAN RIGHTS COMMISSION NN BOARD OF EDUCATION LOCAL SEMI-MONTHLY CHAPTER MEETING FORT DEFIANCE CHAPTER BLACK MESA REVIEW BOARD NAVAJO/HOPI LAND COMMISSION OTHER SPECIFY COALMINE CHAPTER COUNCILMEN SALARY ADVANCE CHAPTER OFFICERS ONLY CHECK ONE OF THE FOLLOWING LOCAL CHAPTER MEETING PLANNING MEETING AGENCY MEETING ALL OTHERS --- CHECK ONE OF THE FOLLOWING LAND FARM BOARD DISTRICT GRAZING COMMITTEE RETIREMENT PAYOUTS EASTERN NAVAJO LAND BOARD DESCRIPTION OF MEETING LOCATION OF MEETING S PURPOSE OF MEETING OR ITEMS DISCUSSED USE BACK IF NECESSARY DATE S FROM TRAVEL INVOLVED TO TOTAL MILES AMOUNT OF CLAIM CONTROLLER S OFFICE USE ONLY ACCOUNT NO. DAYS PER DIEM FUNDS AVAILABLE BY I certify that this claim is true and just to the best of my knowledge and that the amounts claimed are due to me and have not been previously paid* If approved I request that the check be ready by time on date. I request that the check be check one Mailed to me at the address OTHER EXPENSES ATTACH RECEIPTS Picked up by myself Picked up by person other than myself name ADVANCE REQUESTED LESS DEDUCTIONS TOTAL SIGNATURE OF CLAIMANT CLAIM APPROVED BY CHAIRMAN N*T*C. COMMITTEE CHAIRMAN CHAPTER PRES* ETC. SIGNATURE CONTROLLER S APPROVAL ADVANCES ONLY CURRENT ADVANCE BALANCE ADVANCE RECORDED PAYROLL. DAYS PER DIEM FUNDS AVAILABLE BY I certify that this claim is true and just to the best of my knowledge and that the amounts claimed are due to me and have not been previously paid* If approved I request that the check be ready by time on date. I request that the check be check one Mailed to me at the address OTHER EXPENSES ATTACH RECEIPTS Picked up by myself Picked up by person other than myself name ADVANCE REQUESTED LESS DEDUCTIONS TOTAL SIGNATURE OF CLAIMANT CLAIM APPROVED BY CHAIRMAN N*T*C. I request that the check be check one Mailed to me at the address OTHER EXPENSES ATTACH RECEIPTS Picked up by myself Picked up by person other than myself name ADVANCE REQUESTED LESS DEDUCTIONS TOTAL SIGNATURE OF CLAIMANT CLAIM APPROVED BY CHAIRMAN N*T*C. COMMITTEE CHAIRMAN CHAPTER PRES* ETC. SIGNATURE CONTROLLER S APPROVAL ADVANCES ONLY CURRENT ADVANCE BALANCE ADVANCE RECORDED PAYROLL. DAYS PER DIEM FUNDS AVAILABLE BY I certify that this claim is true and just to the best of my knowledge and that the amounts claimed are due to me and have not been previously paid* If approved I request that the check be ready by time on date. I request that the check be check one Mailed to me at the address OTHER EXPENSES ATTACH RECEIPTS Picked up by myself Picked up by person other than myself name ADVANCE REQUESTED LESS DEDUCTIONS TOTAL SIGNATURE OF CLAIMANT CLAIM APPROVED BY CHAIRMAN N*T*C. COMMITTEE CHAIRMAN CHAPTER PRES* ETC. SIGNATURE CONTROLLER S APPROVAL ADVANCES ONLY CURRENT ADVANCE BALANCE ADVANCE RECORDED PAYROLL. .

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