Form 4102, 2014, Contract/application For Travel Advance printable pdf download

Texas Dept. of Aging and

Form 4102

Contract/Application for Travel Advance

Disability Services

April 2014

To avoid processing delays, complete all items.

Original signatures must be in ink (fax copies cannot be accepted).

For further information, see the Operational Handbook, Item C-4132.

1. Requesting Employee (Last Name, First Name, Middle Name)

2. Payee Identification No. (PIN)

3. Employee ID No. (11 Digits)

6. Area Code and Telephone

4. Designated Headquarters (Street Address, City, State, ZIP)

5. Mail Code

(

)

–

7. Destination/Training Site (Building Name, Street Address, City, State, ZIP)

8. Mail Code (if applicable)

9. Type of Travel/Training

10. Name of Trainer (if Training)

11. Trainer's Area Code and Telephone No.

(

)

–

12. Travel/Training Dates (mo./day/yr.)

13. Schedule of estimated travel expenses

From:

To:

Meals:

Number of Days ........

Lodging:

No. of nights ..............

Mileage:

(Mileage is limited to one round-trip)

Total Estimated Travel Expenses ...................................................................................

80% Of Total Estimated Travel Expenses: (This is the amount of your advance.) ..........

•

Note:

Advance funds are NOT available for daily round trips in lieu of overnight stays.

•

All other claims from public transportation, parking, and incidental expenses may be submitted on the settlement voucher.

•

Airfare will NOT be considered on a travel advance.

•

Receipts for commercial lodging must be attached to the settlement voucher.

•

A copy of the signed Form 4186 must be attached to this application for out-of-state trips.

14.

I hereby certify that the above information and estimations are true and as accurate as possible and that the funds

will be used solely for the travel estimated above. I also agree to submit a complete and valid State of Texas Travel

Voucher (Form 4104) listing the actual expenses for this trip within 10 working days of the travel completion date. I

also understand that this travel voucher will be marked "settlement" across the top and that a check or money

order will be attached to the claim for the FULL amount owed if the settlement claim is less than the amount

advanced. Under TEX. REV. CIV. STAT. ANN. art. 4350, any payments due to me from the State of Texas may be

withheld until all debts owed by me to the State are paid (including failure to submit a settlement voucher). In

addition, I understand that the Texas Department of Aging and Disability Services may take adverse personnel

action against me if I fail to settle this claim in a timely manner.

Signature-Requesting Employee

Date

Home Address (Street Address, City, State, ZIP)

Area Code and Telephone No.

(

)

–

15.

Supervisor Approval: As approving supervisor, I understand that it is my responsibility to ensure that this employee settles

this advance claim in a timely manner according to the laws of the State of Texas and the rules and regulations of the Texas

Department of Aging and Disability Services. I also understand that I am responsible for ensuring full and proper settlement

of all advances given to resigning employees.

Full Name (type or print)

Signature-Supervisor

Date

Designated Headquarters (Street Address, City, State, ZIP)

Mail Code

Area Code and Telephone No.

(

)

–

Accounting Use Only

Check No.

Amount

Form 4102, 2014, Contract/application For Travel Advance

Related Articles

Related forms

Related Categories