Liability Date (MM) (DD) (YY) / Payee ID / Route Payee Amount / MIR Date (MM) (DD) (YY) / S P A C E Payee Name (Last) S P A C E FI S P A C E MI Suffix IRS Code IRS Amount Address Stat Type Statistic Address Ref/Inv Number (14 additional spaces) Indicator Dept / Ind Statewide TRAVEL City State Zip Ref/Inv Date (MM) (DD) / Purpose of Travel Official Station Destination (including county) Residence Departure Date And Time Return Date And Time Neg Unit 1) Indicate All Travel Expenses - Use detail sheet if necessary Lodging days CTA: (YY) / Yes No 2) Summary A..
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