Travel Reimbursement Form
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1Travel Reimbursement
Original Itemized Receipts Required
THIS WILL NOT BE SUBMITTED FOR REIMBURSEMENT UNLESS YOU SIGN THE PAYEE
SIGNATURE LINE & YOU HAVE AUTHORIZATION
Pre-Trip
Final
Travel #: ____________
Date: _________________
Name:
U of Utah ID:
__________________________________________
___________________________
Email:
Phone:
__________________________________________
_________________________________
Class/Team Name & Number: _________________________________________________________
Chartfield: 01 - 00068 - ________ (
) - _________________ (
)
Fund
Activity or project
!"#$%&'(($)*+,&!-.($/0$1#23/1#4$561$788$#9:86;##<0=34#>=$1#/9?310#9#>=0@$7>4$930=$/>A834#$7$1#747?8#$:1/>=$65$="#/1$>79#@$3,*B<(9:8*B@$
7>4$#97/8$7441#00!$
I certify that these expenses were actual, necessary, reasonable and incurred for official business of the University of Utah and that no
portion of this claim was provided free of charge, previously reimbursed from any other source, or will be paid from any other sources in
the future.
PAYEE SIGNATURE_____________________________________ DATE_______________________
Authorized by: _______________________________________________________________________
(Faculty signature required)
Reason for Trip: _________________________ Destination: _______________________________
Departure Date: _____/_____/_____
Return Date: _____/_____/_____
Mail reimbursement to: ________________________________________________________________________________
(If other than MEB 2110) _______________________________________________________________________________
AIRFARE: Name of Airline: _____________________ Paid By ___University
$_______________
airfare
___Traveler
**Call travel agent for state contract rate maximum prior to purchase.
PERSONAL AUTO
$_______________
personal auto
**_________ Miles @ (Mileage allowance) - $.50/mile or ($.36/mile Fleet Vehicle)
(If flying to destination you cannot claim mileage for personal auto)
LODGING
Paid By___ University
$_______________
___ Traveler
lodging
Hotel Name: ___________________________
Non-conventional: __________________
MEAL EXPENSE
$_______________
meal expense
Per Diem __________ Days @ $_________/Day
st
(1
and last day of travel are reimbursed at 75% of per diem.)
Flat Amount set by PI $___________
(If claiming exact cost up to 120% of per diem, itemized receipts are required)
CONFERENCE REGISTRATION
$_______________
registration
Are you presenting?
Yes
No
Are any meals provided?
Yes
No
How did you pay? ____________________
CAR RENTAL
$_______________
car rental
Car Rental Name____________________________
**Car Rental Agencies (Contract #) – National/Enterprise (XZ47075) Hertz (0198552)
If not using contract rates there will be a $3 /day insurance surcharge.
Taxi, Bus, Shuttle, Etc.
$________________
Parking
$________________
Gasoline
$________________
Other
$________________
Subtotal
$
_______________
Graduate School / Other Contribution (Subtract)
$_________________
Total
$_______________
Revised April 2011
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