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Travel Advance Request Form

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Bursar to Complete:

Batch#: ____________

Check No: ________________

Date: ______________

Amount: $

UNIVERSITY OF CONNECTICUT HEALTH CENTER

TRAVEL ADVANCE REQUEST FORM

FORM MUST BE TYPED

Please complete sections A and B and forward to Bursar’s Office, Munson Rd. MC5105

SECTION A:

Traveler’s Name:

Department:

Banner #:

Mail Code:

Phone:

State Employee #:

TA Number:

Destination

Depart Date:

Return Date:

SECTION B: Travel Advance Criterion for expenses on trips.

Out of pocket expenses range

Your Advance is

$100 - $249

$100

$250 - $500

$250

$501 - $1250

$500

$1251 or more

$1000

AMOUNT REQUESTED:

Note: Please be sure NOT to include airfare or registration in the amount requested.

SECTION C:

PROMISSORY NOTE

For value received, I ____________________________________promise to pay to the order of the University of Connecticut

Health Center, on demand the sum of _____________________, said amount representing an advance to me.

I agree that within five (5) working days after my return, I will submit a completed Request for Reimbursement of Expenses, with

the required documentation, to the General Accounting Department, MC5305. Any travel advances should be paid within ten (10)

working days after completion of the trip.

I also agree, if these conditions are not met, that this amount may be deducted from my paycheck, or other monies due to me at

the time, and in the manner Health Center Officials deem necessary and appropriate. I also understand that future advances

may be withheld if I do not comply.

SECTION D:

(To be completed when check is received)

RESET

I hereby acknowledge and agree to the above:

Traveler’s Signature:______________________________________________________ Date: ________________

FOR TRAVEL OFFICE USE ONLY

Travel Office Signature

Date:

Credit Memo Processed

Date:

REMEMBER TO POST DATE CREDIT MEMO FIVE (5) DAYS FROM TRAVELER RETURN DATE

Travel Advance Request Form

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