TOTAL EXPENSES Updated 6/16/05 MILEAGE EXPENSES DATE ACCT # PLACE ADDRESS PHONE ONE-WAY MILEAGE NOTES                                                                                                                           TOTAL ONE-WAY MEDICAL MILES       Per the Internal Revenue Service:  "The standard mileage rate for moving or medical reasons was __ cents per mile for the year ______." DOUBLE ONE-WAY MILES FOR ROUND TRIP MILES   TIMES __¢   TOTAL MILEAGE EXPENSES $   POSTAGE AND ENVELOPES   DATE TO ENVELOPES POSTAGE REASON                                                   TOTAL ENVELOPE EXPENSES      $ TOTAL POSTAGE EXPENSES      $               TOTAL POSTAGE & ENVELOPE EXPENSES $                       MEDICAL EXPENSES DATE ACCT # PLACE ADDRESS PHONE AMOUNT DATE PD NOTES                                                                                               TOTAL MEDICAL EXPENSES $                                               PROPERTY DAMAGE EXPENSES   COPIES DATE ITEM AMOUNT   DATE QTY AT __¢ EACH                                                                                   TOTAL PROPERTY DAMAGE EXPENSES $                                                   LOSS OF EARNINGS               DAYS HRS/DAY TOTAL HOURS HOURLY WAGE                                     TOTAL LOSS OF EARNINGS $       TOTAL COPIES $                                             ALL TOTALS   MEDICAL EXPENSES $   MILEAGE EXPENSES $   LOSS OF EARNINGS $   POSTAGE AND ENVELOPES $   UNPAID PROPERTY DAMAGE EXPENSES $ COPIES $   TOTAL OWED $

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