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Pa Travel Reimbursement Form

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Veterans Research

TRAVEL

Foundation of Pittsburgh

REIMBURSEMENT

University Drive C

Building 30 Ground Floor

FORM

Pittsburgh, PA 15240

Main# (412) 360-2403 Fax# (412)360-2393

Name of Traveler:

Home Address:

City:

State:

Zip:

Work Phone:

Work Ext.

Mail Code:

Alternate Phone #:

Preferred Method of Payment:

Mail Check

Call for Pickup

Destination of Trip:

Departure Date/Time:

Return Date/Time:

Please attach conference agenda. Per diem can be found at

1.Meals & Incidentals

Original itemized invoice showing $0 balance

2. Lodging/Hotel

Itinerary and proof of payment

3. Airfare

Receipts required

4. Ground Transportation (Taxi,

Bus, Shuttle)

Receipts required

5. Parking

Copy of registration form and proof of payment

6. Registration Fees

Receipts required

7. Other Expenses – Please Explain

8. Car Rental

Original car rental slip and proof of payment

9. Private Car Use:

Driven From:

Driven To:

Total # of Miles

x .54 cents/mile

Total (1-9) Expenses

(attach original

Please note that if the above listed

receipts for all expenses including copies of

documents are not included with the

prepaid items)

travel reimbursement request, the

Less Prepaid Expenses (attach copy

request will be returned to the

of previously paid request form)

traveler

Amount Due Traveler or Amount

Due VRFP

(attach check payable to

Veterans Research Foundation of Pittsburgh)

I certify that the above is a true statement of the travel expense incurred by me during the date(s) shown on this claim, that all items were for the

official business of the Veterans Research Foundation of Pittsburgh or VA approved research studies or education activities, and that if my

personal vehicle was used it was covered by the minimum liability insurance required by travel regulations.

Travelers Signature

Date

By signing this form, I hereby attest that the funds being disbursed are for goods and/or services related specifically to the grant, contract or other

funding source associated with this project.

P.I. Signature (if applicable)

Date

Executive Director Signature

Date

PROJECT CHARGEBACK: