AC3256-S (Effective 1/12)

State of

New York

STATEMENT OF STATE CORPORATE TRAVEL CARD CHARGES

Submit with expense report

Name Travel Start Date Travel End Date

Date Vendor Name Amount

Total State Corporate Card Charges (Report on AC132-S in Section 2C)

Name: Travel Start Date: Travel End Date: DateRow1: Vendor NameRow1: AmountRow1: DateRow2: Vendor NameRow2: AmountRow2: DateRow3: Vendor NameRow3: AmountRow3: DateRow4: Vendor NameRow4: AmountRow4: DateRow5: Vendor NameRow5: AmountRow5: DateRow6: Vendor NameRow6: AmountRow6: DateRow7: Vendor NameRow7: AmountRow7: DateRow8: Vendor NameRow8: AmountRow8: DateRow9: Vendor NameRow9: AmountRow9: DateRow10: Vendor NameRow10: AmountRow10: DateRow11: Vendor NameRow11: AmountRow11: DateRow12: Vendor NameRow12: AmountRow12: DateRow13: Vendor NameRow13: AmountRow13: DateRow14: Vendor NameRow14: AmountRow14: DateRow15: Vendor NameRow15: AmountRow15: DateRow16: Vendor NameRow16: AmountRow16: DateRow17: Vendor NameRow17: AmountRow17: DateRow18: Vendor NameRow18: AmountRow18: DateRow19: Vendor NameRow19: AmountRow19: DateRow20: Vendor NameRow20: AmountRow20: DateRow21: Vendor NameRow21: AmountRow21: DateRow22: Vendor NameRow22: AmountRow22: DateRow23: Vendor NameRow23: AmountRow23: DateRow24: Vendor NameRow24: AmountRow24: DateRow25: Vendor NameRow25: AmountRow25: DateRow26: Vendor NameRow26: AmountRow26: DateRow27: Vendor NameRow27: AmountRow27: DateRow28: Vendor NameRow28: AmountRow28: DateRow29: Vendor NameRow29: AmountRow29: DateRow30: Vendor NameRow30: AmountRow30: AmountTotal State Corporate Card Charges Report on AC132S in Section 2C: