Domestic Travel Reimbursement Worksheet
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1
2DOMESTIC TRAVEL
REIMBURSEMENT WORKSHEET
Submit completed form along with all original receipts to your travel processor
Name: _________________________________
Date: ________________________________
SS#/Employee ID#: _____________________
UC Employee: Yes No
Address: ______________________________
U.S. Citizen: Yes No
______________________________
City of Residence: ______________________
Phone: ______________________________
Vendor ID (if known): ____________________
E-mail Address: ________________________
Home Campus: __________________________
Account to be charged: _____________________________________________________________
Purpose of Travel: ______________________________________________________________
Destination: _______________________________________________________________________
Initial Departure Date: __________________ Return Date: ______________________
Initial Departure Time: _________________ Return Time: ______________________
Yes _____ Amount: $__________
Did you obtain a Travel Advance for this trip? No______
Was there any personal time during this trip? No
Yes From: ____________ To: ____________
MEALS AND INCIDENTAL EXPENSES (LIST ACTUAL EXPENSES ON PAGE 2)
Actual amount spent on meals listed on daily log. You may claim up to $74 per day.
There is no per diem for Domestic (See page 2 for daily log.)
LODGING
Did you share a room? Yes____
No____ If so, with whom? ___________________________
Number of nights: ________ Rate: $__________ Tax: $__________ Other: $__________
Number of nights: ________ Rate: $__________ Tax: $__________ Other: $__________
Number of nights: ________ Rate: $__________ Tax: $__________ Other: $__________
TRANSPORTATION
Airfare: $_____________ RT Paid for by: Credit Card______
Charged to Department _______
Private Car Mileage: ________ License Plate #: ___________
Check here to confirm your liability insurance
Rental Vehicle: $_____________ Rental Vehicle Gasoline: $___________ UC Vehicle: Yes
No
Taxi/Bus: $____________ Train: $____________ Other: $__________
MISCELLANEOUS
Registration: $__________ Tele/Fax/Internet: $_________ Parking: $___________ Other (explain):
$____________
Comments: ____________________________________________________________________________
SIGNATURES
I certify that the above is a true statement, that the expenses claimed were incurred
by me on official University business on the dates shown, and that I have attached
AUTHORIZING SIGNATURE DATE_
original receipts for each expense of $75 or more, as required by University policy.
______________________________________________________________
_____________________________________________________________________
AUTHORIZING SIGNATURE DATE
Print name and title
(Page 1 of 2)
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