Form Cgauxa-3a - Claim For Reimbursement - Travel Form - Coast Guard Auxiliary Association
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Rev 001
COAST GUARD AUXILIARY ASSOCIATION, INC.
CGAuxA-3A (1/08)
CLAIM FOR REIMBURSEMENT - TRAVEL FORM
NAME ________________________________________ AUXILIARY OFFICE _____________________
ADDRESS ________________________________________ BUDGET ACCOUNT ____________________
CITY
________________________________________ ST ____ ZIP
___________________________
EMAIL ________________________________________ PHONE _______________________________
Check here
if not grant associated travel. If travel WAS performed in conjunction with a grant, enter:
Grant Name: _________________________________________
Grant Number: _________________
SHARING ROOM / RIDE
ITINERARY
If room / ride was shared with another Auxiliarist covered by
DATE
DEP/ARR
PLACE
a Travel request, enter name and office held here:
DEP
_______________________________________________________
ARR
Shared with
Office
COMMENTS
DEP
ARR
DEP
ARR
DEP
ARR
Category
CGAuxA
Claimant paid
EXPENSE TYPE:
total:
credit card
out-of-pocket
1. Gasoline & oil ..................... $ __________
$ ___________
$ ___________
2. Parking & tolls .................... $ __________
$ ___________
$ ___________
3. Airfare ................................ $ __________
$ ___________
$ ___________
4. Taxi - limousine .................. $ __________
$ ___________
$ ___________
5. Telephone & fax charges .... $ __________
$ ___________
$ ___________
6. Baggage & tips ................... $ __________
$ ___________
$ ___________
7. Hotel .................................. $ __________
$ ___________
$ ___________
8. Hotel taxes ......................... $ __________
$ ___________
$ ___________
9. Other .................................. $ __________
$ ___________
$ ___________
10. Other .................................. $ __________
$ ___________
$ ___________
11. Totals: ................................ $ __________
$ ___________
$ ___________
12. Plus per diem: ..........................................................................
$ ___________
13. Plus lodging allowance: ............................................................
$ ___________
14. Less adjustments, e.g. meals provided/other CC charges, etc.
$ ___________
15. Less previous payments: ..........................................................
$ ___________
16. Reimbursement due claimant: ..................................................
$ ___________
SIGNATURE OF CLAIMANT
Authorized Rates and Days:
Payment has not been received. This statement and all
Per Diem Rate: $ ______ Lodging Rate: $ _____
items attached are true. I am aware that this claim for
reimbursement must be E-mailed & copies of required
Per Diem Days: ____ Lodging Days: ____
receipts faxed to AUXCEN within seven (7) days after
travel is completed.
TRAVEL REIMBURSEMENT APPROVED
____________________________________
Member signature
____________________________________
Authorized signature
8.1E8.102F
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