Travel Advance Request Form

TRAVEL ADVANCE REQUEST

TO: Cashier's Section

OUT OF STATE REQUEST #________________

Division of General Accounting

201 W. Preston Street

ADVANCE NEEDED BY:_______________

Room 540

FROM:

____________________________________

FISCAL APPROVAL: ___________________________

PCA:__________________INDEX:__________

Employee's Name: ______________________________________ DHMH - Regular Employee ___ Special Pymts Employee ___

Home Address: __________________________________ City: ______________________ State: _____ Zip: _________

Employee Office Location: _________________________________ Office phone number: _________________________

Supervisor's Name: _______________________________________ Office phone number: ________________________

Travel Destination: _________________________

Date of Travel: FROM ___________ THROUGH _____________

Purpose:

___________________________________________________________________________________________

DETAIL OF TRAVEL ADVANCE REQUEST:

MEAL

Number of days ____________ X rate allowed _________________ = TOTAL __________________

LODGING Number of days ____________ X rate charged _________________= TOTAL __________________

OTHER

Parking, taxi, etc.

TOTAL __________________

REGISTRATION*** Attach original application form)

TOTAL __________________

$_________________

TOTAL OF TRAVEL ADVANCE REQUEST

*** Registrations requests over $100.00 must be submitted on a Registration Request Form.

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PLEASE READ BEFORE SIGNING

I understand, in accepting this temporary advance, that I MUST SUBMIT TO THE DIVISION OF GENERAL ACCOUNTING(DGA) MY EXPENSE

ACCOUNT WITHIN FIVE (5) CALENDAR DAYS AFTER THE COMPLETION OF THE TRIP, with all receipts attached, along with any unused funds.

If General Accounting does not receive the above within five (5) days, DGA will request Human Resources to capture my payroll check to settle the

advance. DGA will also request Human Resources to capture my payroll check to setttle any balance due after receipt and audit of my Expense

Account. I will receive one (1) notice from DGA prior to this capture, giving me an opportunity to explain why the capture should not proceed.

My failure to respond timely to the notice shall constitute a waiver of my right to be heard. If I do request a hearing, DGA will provide me with its

determination in writing after I have been heard.

I certify that I am a current regular payroll/special payroll employee of the Department of Health and Mental Hygiene

I HAVE READ AND UNDERSTAND THIS AGREEMENT

_______________________________________________________

_____________________

Employee Signature

Date

General Acctg Use

WFReview ________Travel Approved _________ Check No ____________ Amount ___________

Revised 2-08