Travel Reimbursement Request Form

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Travel Reimbursement Request
(Original receipts are required)
NAME OF TRAVELER: ______________________________
UCI Employee ID#__________________________________
Mailing Address:____________________________________
Or if Visitor, Social Security#__________________________
E-mail Address:____________________________________
Please check one of the following:
US Citizen
Travel Store_____________
Foreign Visitor
(Provide copies of a) Visa; and b) I-94 (front & back)
Permanent Resident
Corp Card_____________
(Provide a copy of your Resident Alien Card)
Purpose and Destination of Trip (i.e. Name of Conference, institution):_____________________________________________
Travel Begin/End Dates/Times
: start on ____/____/____ @______ am/pm, to ____/____/____ @______ am/pm
Are you requesting or did you receive any advances? If so, please list.
Airfare: $ _________ Hotel: $ _________ Per Diem: $ __________ Registration: $__________ Other: $ ___________
Ticket #
Amount $ ___________ Attach original ticket receipt & proof of payment.
Amount $___________ Attach receipt(s) include itemized folio and show proof of payment.
Total $
Per Diem/M&IE Rate
Maximum Allowed
# of day’s ___________
Please fill out the table below with the actual amount spent per day on meals. (Include receipts when requesting max per diem.)
Amt Spent:
Conference Registration
Amount $ ___________ Please attach receipt(s)
Car Rental
:Amount $ ___________ Please attach receipt(s) showing payment, and rental agreement number & mileage
Mileage Amount $
# of miles _________
If personal car was used, do
Rate for travel in 2016: 54 cents/mile
you have Liability Insurance? ___Yes or ___No
Other Expenses
Rate for travel in 2015: 57.5 cents/mile
List date and description and provide receipts:
____________________________________ $ _________
____________________________________ $ _________
____________________________________ $ _________
____________________________________ $ _________
Budget Code/
KFS #: __________________________________________
Host/PI Name: __________________________________
COMMENTS/ADDITIONAL NOTES: _______________________________________________________________________
I certify that the above is a true statement, that the expenses claimed were incurred by me on official University Business, on the dates shown, that I have
attached original receipts as required by UC Policy and understand the
Traveler’s Signature: _______________________________________
Date: ____________________________
PI Approval Signature:_______________________________________
Date: ____________________________
Rev 1/7/16
Submit to:___________________________________


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Parent category: Business