Form 823 - Authorization / Request For Out Of State Travel
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AUTHORIZATION / REQUEST FOR OUT OF STATE TRAVEL
State Form 823 (R9 / 4-09)
Approved by State Board of Accounts, 2009
1. Name of agency & division
2. Date of request (
month, day, year
)
3. Agency request number
4. Name of employee (last name, first name, middle initial)
5. Position / title
6. Personal time or weekend added?
Y
Y
Y
N
N
N
Dates:
7. Origin of trip
8. Date and time of departure
9. Date and time meeting starts
10. Trip necessary to fulfill job duties?
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
11. Attending a conference?
12. Destination of trip
13. Date and time of return
14. Date and time meeting ends
15. Contact person:
16. Contact number:
17. Purpose of travel (Use this space to give justification for the trip and why it is in interest of the State that the travel be approved. Provide additional sheet, if necessary.)
ESTIMATED EXPENSES
RATE
AMOUNT
18. Registration fees
$
19. Transportation
Air
Bus
Train
State car
$
Automobile (personal)
___
Miles X
$
0.44
$
0.00
Automobile (rental)
(attach justification and cost)
$
$
20. Lodging (including taxes)
Hotel name & city
Number of days
X
$
$
___
0.00
21. Daily subsistence (per diem)
Number of days
___
X
$
$
0.00
(explain below )
22. Other expenses
$
23. Explanation
0.00
24. Total Cost
$
25. Fund Center Name:
26. Fund Center Number:
General Fund
% State Funds
x total cost
=
$
0.00%
Federal Funds
% Federal Funds
x total cost
=
$
0.00%
Dedicated Fund
% Dedicated Funds
x total cost
=
$
0.00%
Other Source
% Other Source
x total cost
=
$
0.00%
TOTAL cost:
$
I certify 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.
27. Signature of traveler
Date of signed (month, day, year )
28. Signature and title of approving agency official
Date of signed (month, day, year )
AUTHORIZATION
Authorization to travel out of state will be granted only if all approval signatures below have been acquired
Authorization to travel out of state will be granted only if all approval signatures below have been acquired
Signature of Commissioner, Department of Administration
Date of signed (month, day, year )
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