Travel Expense Voucher Form
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1Public Employees Local 71 Trust Fund
Travel Expense Voucher
Member Name:______________________
Patient Name:_______________
Member Alternate ID or SSN Number: ___________________________
Transportation:
Date of Departure: ___________________ Date of Return: ____________________
Private Automobile ____ miles at $0.45 per mile $___________________
Airfare (attach copy of ticket)
$___________________
Ferry (attach copy of ticket)
$___________________
Cab Fare (attach copy of ticket)
$___________________
Lodging:
Date of Check-in: __________________ Date of Check-out: __________________
Hotel or Motel Expense (attach copy of bill)
$___________________
Food: All food expenses must be supported by a receipt.
Date:
___/___/___
___/___/___
___/___/___
Breakfast:
$_________
$_________
$_________
Lunch:
$_________
$_________
$_________
Dinner:
$_________
$_________
$_________
Total:
$_________
$_________
$_________
Date:
___/___/___
___/___/___
___/___/___
Breakfast:
$_________
$_________
$_________
Lunch:
$_________
$_________
$_________
Dinner:
$_________
$_________
$_________
Total:
$_________
$_________
$_________
TOTAL OF ALL DAILY FOOD EXPENSES:
$_______________
Total of Transportation Expense Voucher Request:
$_______________
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Parent category: Life