Form 823 - Authorization For Out Of State Travel - State Of Indiana

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1. Agency Request Number
AUTHORIZATION FOR OUT OF STATE TRAVEL
2. Date of request (month, day, year)
State Form 823 (R5 / 1-04) Formerly G-10
Approved by the State Board of Accounts 2004
INSTRUCTIONS:
In requesting authorization for an employee to travel out of state on official business, this form must be submitted a minimum of
two (2) weeks prior to date of departure. A separate form must be submitted for each employee for whom permission is requested.
This form must be typed.
3. Name of agency
4. Account number
5. Employee telephone number
6. Name of employee (last, first, middle initial)
7. Position title / grade / rating
8. If any portion of this trip to be personal vacation?
If Yes, give dates
9. Origin of trip
10. Destination of trip
Yes
No
11. Date and time of departure
12. Date and time of return
13. Identify employees going on same trip
14. Date and time meeting starts
15. Date and time meeting ends
16. Purpose of travel (use this space to give reasons for the trip and why it is in the interest of the State that the travel be approved. Include the name of the company, workshop, seminar or meeting. YOU MUST
ATTACH A COPY OF THE PROGRAM OR SCHEDULE INCLUDING DOCUMENTATION OF DATES, LOCATION, REGISTRATION AND LODGING.)
ESTIMATED EXPENSES
RATE
AMOUNT
$
17. Registration Fees
18. Transportation
$
Air
Bus
Train
State Car
.34
$
Automobile (personal)
Miles X
Miles X
.17
$
Automobile (rental)
$
(attach justification and costs)
$
Number of days
x
$
$
19. Lodging
(including taxes)
Number of days
x
$
$
20. Daily Subsistence
(per diem)
$ .
21. Other (parking, taxi, etc.)
(explain below)
22. Explanation
23. Total Estimated Cost
$
(if no expense to State, explain)
I certify that the requested travel is in furtherance of State business except as indicated above, and that my reimbursable expenses will be limited to the amounts indicated
above.
24. Signature of traveler
Date signed (month, day, year)
25. Signature and title of approving agency official
Date signed (month, day, year)
AUTHORIZATION
Authorization to travel out of state will be granted only if all approval signatures below have been acquired.
IDOA number
Signature of Commissioner, Department of Administration
Date signed (month, day, year)
Signature of Budget Director (if required by travel regulations)
Date signed (month, day, year)
White-Dept. of Administration, Green-Budget Agency, Canary-Agency, Pink-Agency, Goldenrod-Originator (detach only this copy, forward all others to Dept. of Administration)

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