Check if advance was issued for these expenses
SHORT TERM ADVANCE
SEMA4 EMPLOYEE EXPENSE REPORT
FINAL EXPENSE(S) FOR THIS TRIP?
Home Address (Include City and State)
Permanent Work Station (Include City and State)
1-Way Commute Miles
Trip Start Date
Trip End Date
Reason for Travel/Advance (30 Char. Max) [example: XYZ Conference, Dallas, TX]
Expense Group ID
Agncy Cost 1 Agncy Cost 2
Total Trip &
(no overnight stay)
VEHICLE CONTROL #
MILEAGE REIMBURSEMENT CALCULATION
OTHER EXPENSES – See reverse for list of Earn Codes.
Total Mileage Amt.
1. Enter the rate, total miles, and amount for the mileage listed above being
claimed at a rate less than or equal to the IRS rate. Get IRS rate from your
agency business expense contact.
2. Enter the rate, total miles, and amount for the mileage listed above being
claimed at a rate above the IRS rate. (If no mileage is claimed above the
IRS rate, enter zero.)
3. Add the total mileage amounts from lines 1 & 2.
4. Enter IRS mileage rate in place at the time of travel.
5. Subtract line 4 from line 2.
6. Enter total miles from line 2.
Subtotal Other Expenses:
Total taxable mileage greater than IRS rate to be reimbursed:
7. Multiply line 5 by line 6. This is taxable mileage.
(Copy to Box C)
MIT or MOT
8. Subtract line 7 from line 3. If line 7 is zero, enter mileage amount from line 1.
Total nontaxable mileage less than or equal to IRS rate to be reimbursed:
This is non-taxable mileage.
(Copy to Box D)
MLI or MLO
Grand Total (A + B + C + D)
If using private vehicle for out-of-state travel: What is the lowest airfare to the destination?
Total Expenses for this trip must not exceed this amount.
I declare, under penalty of perjury, that this claim is just, correct and that no part of it has been paid or reimbursed by the state of Minnesota or by another party except with respect to
Less Advance issued for this trip:
any advance amount paid for this trip. I AUTHORIZE PAYROLL DEDUCTION OF ANY SUCH ADVANCE. I have not accepted personal travel benefits.
Total amount to be reimbursed to the employee:
Amount of Advance to be returned by the employee by deduction from paycheck:
Employee Signature _________________________________________________ Date _____________________Work Phone ________________________
Approved: Based on knowledge of necessity for travel and expense and on compliance with all provisions of applicable travel regulations.
Appointing Authority Designee (Needed for Recurring Advance and Special Expenses)
Supervisor Signature __________________________________________ Date _______________ Work Phone ______________________
Signature ____________________________________________________________ Date ________________________