Form Fm-1104 - Request For Travel Expense Advance/reimbursement
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TRAVEL SUMMARY ________ - ________ SCHOOL YEAR
This will be the _________ out-of-state trip
(No. of Trips)
This request in-state _____ out-of-state _____
No. Workdays _____
for this employee this ________ school year.
Number of previous trips in-state ______
No. Workdays _____
(Year)
Number of previous trips out-of-state _____
No. Workdays _____
REQUEST FOR TRAVEL EXPENSE
(See Reverse.)
Total previous trips _________
Total Workdays _____
ADVANCE/REIMBURSEMENT
EMPLOYEE NAME ____________________________________________ TITLE ________________________________ EMPLOYEE NUMBER _________________ DATE ___________________
EMPLOYEE SCHOOL/DEPT. ______________________________________________________________________________ WORK LOCATION NUMBER ______________ PAYCODE ________
I respectfully request approval of Expenses and Temporary Assignment of Duty from __________________________________________ to __________________________________________ to attend
________________________________________________________ as a ____________________________________________ and _________ other days taken as ________________________
(Description of conference, meeting, etc.)
(Presenter, student, participant, etc.)
(Personal, vacation, etc.)
LOCATION ___________________________________________________________________ SIGNATURE _____________________________________________ DATE
City
State
ESTIMATED
TRAVEL DATA
ACTUAL
DEPARTURE:
Date _________________ Time _____________
PLEASE CHECK MODE OF TRAVEL:
Date _________________ Time _____________
DEPARTURE:
Air:
MDCPS
Individual
Date _________________ Time _____________
Private Vehicle:
Driver
Passenger
Date _________________ Time _____________
RETURN:
RETURN:
Other ___________________________________
ADVANCE
EMPLOYEE/
-
DESCRIPTION OF EXPENSES
ESTIMATED
REQUISITION #
=
ACTUAL
DUE
MDCPS
REQUESTED
A. Transportation
$
1.
Common Carrier - minimum rate (specify) = $ _________________
$
$
$
2.
Private vehicle: ______________ miles x ___________ rate
3.
Car rental (see reverse)
4.
Taxi, tolls, parking, etc. (attach original receipts)
B. Per Diem Option: _______ Days
* Hotel = $ _____________
(OR)
X $ ____________ = $ ____________
Meals = $ _____________
C. Incidental (attach original receipts)
SUB-TOTAL
$
$
$
$
D. Registration/Tuition (attach original receipts)
* Florida State Sales Tax is not to be paid on hotel room.
TOTAL
$
$
$
$
Use Tax Exempt No. 23-08-324893-53C
CHARGE TO:
FUND
WORK LOC.
OBJECT
PROGRAM
FUNCTION
CHARGE LOC.
INTERNAL FUND
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AUTHORIZATION:
AFTER TRAVEL:
CERTIFICATION OF AVAILABLE FUNDS
I certify that these expenses were actually incurred by me as necessary traveling
expenses in the performance of my official duties, and are true and correct to the
best of my knowledge and belief.
__________________________________
_______________________________
_____________________________
_________________
Supervisor of Charge Location (Typed)
Signature
Title
Date
EMPLOYEE ____________________________________
_________________
TRAVEL APPROVED
(Signature)
Date
APPROVED
_________________________________
_______________________________
_____________________________
_________________
________________________________
_________________
FOR PAYMENT
Supervisor of Employee (Typed)
Signature
Title
Date
Supervisor of Charge Location (Typed)
Date
Approval up
TRAVEL APPROVED
to $ 2, 500
________________________________
________________________________
Signature
Title
_________________________________
_______________________________
_____________________________
___________
FM-1104 Rev. (10-07)
Superintendent of Schools or designee (Typed)
Signature
Title
Date
(See Reverse)
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