Pa Travel Reimbursement Form

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Veterans Research
Foundation of Pittsburgh
University Drive C
Building 30 Ground Floor
Pittsburgh, PA 15240
Main# (412) 360-2403 Fax# (412)360-2393
Name of Traveler:
Home Address:
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)
Amount Due Traveler or Amount
(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
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)
Executive Director Signature


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