OMB No. 0581-0178

F/H Form H (Exp. 3/31/2024) Destroy previous editions.

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823; Fax: (503) 678-6825

STATEMENT OF EXPENSE

If you have no expense, please so state, sign and return this form.

NAME ______________________________________________________________________________

ADDRESS ___________________________________________________________________________

Expenses incurred attending _____________________________________________________________

Miles ___________ @ _________ $ ________________________

Other _______________________ $ ________________________

Expenses incurred attending _____________________________________________________________

Miles ___________ @ _________ $ ________________________

Other _______________________ $ ________________________

Expenses incurred attending _____________________________________________________________

Miles ___________ @ _________ $ ________________________

Other _______________________ $ ________________________

Miscellaneous expenses (please itemize below) ______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

TOTAL $ ________________________

_______________________________________

Signature

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