Claim For Employee Travel Expense Form

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Financial Services Use Only
CLAIM FOR EMPLOYEE TRAVEL EXPENSE
Clear Expenses From Travel Request
Use This Form To
Prepared by: ____________________ Ext.: _______
Date: _______________________________________________
I declare under penalties of perjury that this claim (including any
accompanying evidence) has been examined by me and to the best
of my knowledge and belief is a true and correct claim in best
Employee ID No.: _____________________________________
conformance with the governing statutes and the rules and
regulations as promulgated by the Board of Examiners.
Name: ______________________________________________
I do
I do not have a travel advance
Title: _______________________________________________
Claimant Signature Required
Date
Sort Code / Extension: _________________________________
TRAVEL EXPENSE WORKSHEET
Travel Date
Day of Week
Departure Time
Arrival Time
Return Time
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Total
Airfare
Hotel
$ 0.00
Room Tax / Fees
$ 0.00
$ 0.00
Auto Rental
$ 0.00
Taxi / Bus / Shuttle
$ 0.00
Mileage
$ 0.00
Fuel / Tolls
Hotel Parking
$ 0.00
Airport Parking
$ 0.00
$ 0.00
Calls / Internet
$ 0.00
Meals / Incidentals
$ 0.00
Miscellaneous
$ 0.00
Meals Not Claimed
Total
$ 0.00
Breakfast
Lunch
Dinner
I/E
Total
Federal Per Diem Rate
Maximum Lodging
$ 0.00
Federal Lodging Rate
Total
$ 0.00
NOTE: With the exception of per diem and incidental expenses, all claimed expenses must be documented. In-state
travel requires the approval of the dean/director. Out-of-state travel also requires the approval of the vice president.
Approved by Dean/Director
Date
Approved by Vice President
Date
ACCOUNTING INFORMATION
CLAIM SUMMARY
Total of this Claim
(complete ll fields)
FUND
AREA
ORGN
OBJ
SOBJ
AMOUNT
Air Fare to Travel Agency
$ 0.00
Prepaid Expenses (Team/Group)
T1
22
Balance of Claim
22
T2
$ 0.00
Advance Received
22
T8
(Total must match worksheet total)
Balance Due Traveler (College)
TOTAL
$ 0.00
$ 0.00
DISTRIBUTION: ONE COPY - FINANCIAL SERVICES J1C
ONE COPY - DEPARTMENT
Revised 6/11
Revised 4/13

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