Travel Claim Form - Washington County
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1Update: April 10, 2017
A separate form must be
WASHINGTON COUNTY
used for each claimant.
TRAVEL CLAIM
Employee
Department
Date
Business
Destination
Purpose
EXPENDITURES (Expenses of this trip to be paid directly to others :)
$
* Registration Fees
Paid To:
$
* Lodging
Paid To:
$
* Air fare
Paid To:
* These items need full documentation, (i.e., a completed registration form, ticket, invoice, agenda, etc.)
PERSONAL AUTO MILES TRAVELED
___
Motor Pool Vehicle was Available: Yes ___
No
Date asked: ___________
Supervisor Initials: ______
DEPARTED FROM
DESTINATION
MILES
Personal Auto Total Miles Traveled:
0
$
Motor Pool AVAILABLE ($0.270 per mile reimbursement):
0.00
$
Motor Pool NOT AVAILABLE ($0.535 per mile reimbursement):
0.00
$
OR Fuel Receipts:
:
0.00
TOTAL MILEAGE OR FUEL RECEIPT REIMBURSEMENT AMOUNT
$
0.00
MEALS AND LODGING
TIME
TIME
GSA
DATE
DEPARTED
RETURNED
RATE
QTY
AMOUNT
BREAKFASTS
$
$
0.00
0
0.00
LUNCHES
$
$
0.00
0
0.00
DINNERS
$
$
0.00
0
0.00
General Services Administration (GSA)
LODGING
$
$
0.00
0
0.00
(Attach Detail List of Incidental Expenses)
INCIDENTALS
$
0.00
0
0.00
$
TOTAL MEALS, INCIDENTALS, & LODGING REIMBURSEMENT
0.00
TOTAL TRAVEL CLAIM REIMBURSEMENT
0.00
$
PER DIEM ALLOWANCE
IRS Code 9864- Sec 163
see
/
Leave at
Return at
Lodging:
Meal
or Before:
or After:
GSA Rate
Lodging without receipts: $40.00
Breakfast
7:00 am
9:00 am
$_______
0.00
Lunch
11:00 am
2:00 pm
$_______
UT Lodging Sales Tax Account is 10-4960-809000
0.00
Dinner
5:30 pm
8:00 pm
$_______
0.00
I certify that the amounts claimed are accurate and per County policy.
Name:
Account #
Signature
Address:
Department Head or Commission Designee Approval
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