Claim For Reimbursement - Travel Form - Coast Guard Auxiliary First District Northern Region
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1Coast Guard Auxiliary First District Northern Region
D1NR AUX‐1
CLAIM FOR REIMBURSEMENT‐TRAVEL FORM
(5‐2011)
NAME____________________________________ MEMBER NUMBER___________________________
ADDRESS__________________________________ AUXILIARY OFFICE____________________________
CITY____________________________________STATE_____ZIP CODE___________________________
ITINERARY(INCLUDE ZIP CODE)
SHARING ROOM/RIDE
IF ROOM/TRAVEL WAS SHARED WITH ANOTHER
DATE
DEPT/ARR
PLACE
AXILIARIST COVERED BY A TRAVEL REQUEST, ENTER
DEP
NAME/POSITION
ARR
DEP
SHARED WITH
ARR
DEP
PURPOSE OF TRAVEL
ARR
____________________________________________
DEP
____________________________________________
ARR
____________________________________________
DEP
ARR
____________________________________________
DEP
____________________________________________
ARR
EXPENSE TYPE:
CLAIMANT PAID
E
X
OUT –OF‐POCKET
P
E
1. FUEL…………………………………………………………. $__________
N
S
2. PARKING & TOLLS………...………………………….. $__________
E
3. TELEPHONE/FAX/PHOTOCOPY…..……………… $__________
S
4. MEALS………………………………………………………. $__________
C
5. LODGING………………………………………………….. $__________
L
6. LODGING TAXES……………………………………….. $__________
A
I
7. OTHER
.................................................. $__________
(EXPLAIN))
M
8. OTHER
.................................................. $__________
(EXPLAIN))
E
9. TOTAL………………………………………………………. $__________
D
PURPOSE FOR TRAVEL APPROVED
SIGNATURE OF CLAIMAINT
Payment has not been received. This statement
and all items attached are true. I am aware that
this claim for reimbursement must be completed
_____________________________________
___________
(Office)
and forwarded within seven (7) days after travel is
Travel Authorization Signature [or attach e‐mail]
completed.
_____________________________ __________
_____________________________________
___________
(Office)
Member signature Date
Disbursement Authorization Signature
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