State Form 823 - Authorization For Out Of State Travel

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1. Agency Request Number

AUTHORIZATION FOR OUT OF STATE TRAVEL

State Form 823 (R4 / 9-00) Formerly G-10

2. Date of request (month, day, year)

Approved by the State Board of Accounts 2000

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. Is any portion of this trip to be personal vacation?

If Yes, give dates

Yes

9. Origin of trip

10. Destination of trip

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

Miles X

.28

Automobile (personal)

Miles X

.14

Automobile (rental)

(attach justification and costs)

19. Lodging

Number of days _____ X

(including taxes)

(cannot be claimed for meals

20. Daily Subsistence

provided or covered in the

Number of days _____ X

(per diem)

registration fee)

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)

Distribution: White - Department of Administration; Green - Budget Agency; Canary, Pink - Agency; Goldenrod - Originator (detach ONLY this copy, forward all others to Department of Administration)