Form Cgauxa-3 - Claim For Reimbursement - Travel Form - Coast Guard Auxiliary Association
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Rev 001
COAST GUARD AUXILIARY ASSOCIATION, INC.
CGAuxA-3 (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
Claimant paid
EXPENSE TYPE:
out-of-pocket
1. Gasoline & oil ............................................................................... $ ___________
2. Parking & tolls .............................................................................. $ ___________
3. Airfare .......................................................................................... $ ___________
4. Taxi - limousine ............................................................................ $ ___________
5. Telephone & fax charges .............................................................. $ ___________
6. Baggage & tips ............................................................................. $ ___________
7. Hotel taxes ................................................................................... $ ___________
8. Other ............................................................................................ $ ___________
9. Other ............................................................................................ $ ___________
10. Totals: .......................................................................................... $ ___________
11. Plus per diem: ..........................................................................
$ ___________
0.00
12. Plus lodging allowance: ............................................................
$ ___________
0.00
13. Less adjustments, e.g. meals provided, etc. .............................
$ ___________
14. Less previous payments: ..........................................................
$ ___________
15. Reimbursement due claimant: ..................................................
$ ___________
0.00
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 completed and forwarded within
Per Diem Days: ____ Lodging Days: ____
seven (7) days after travel is completed in accordance
with the instructions on page 2 of this form.
TRAVEL REIMBURSEMENT APPROVED
____________________________________
____________________________________
_________________
Member signature
Date
Authorized signature
7E7.08F
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