1. Department: Insert the traveler's employing department.
2. Traveler's Name: Insert the name of the traveler.
3.
Address: Insert the traveler's mailing address. This address
is necessary to assure reimbursement checks are mailed to the correct
address.
4. Traveler's Emp ID: Insert traveler's
employee ID number.
5. For the Month of: Insert the month or period in which travel
occurred.
6. Date Submitted: Insert the current date.
7. Section A: Mileage
a. Date of travel: Insert the date of travel.
b.
Destination: Insert city and company where you traveled.
c.
Purpose of Travel: Insert the business purpose for which this
travel was necessary.
d. Number of Miles: Insert the
number of miles you traveled which are reimbursable.
e. Rate
per mile: Insert the current IRS rate per mile, which is
available from the Purchasing Office or from the
web site
f. Total: Multiply the number of miles by the rate per mile
to get the total.
g.Total Mileage: Insert the sum of the Total column in the Total
Mileage box.
8. Section B: Parking Fees and Tolls
a. Date of Charge: Insert the date in which parking fees and/or
tolls were paid.
b. Purpose of Travel: Insert the business purpose for which this
travel was necessary.
c. Amount: Insert the actual amount paid in parking fees and/or
tolls. Attach receipts for reimbursement.
d. Total Parking Fees and Tolls: Insert the sum of the Amount
column in the Total Parking Fees and Tolls box.
9. Section C: Registration Fees and Other
a. Date of Charge: Insert the date for which registration fees
or business meals were paid or other expenses incurred.
b. Event Name: Insert the name of the event for which the expenses
were incurred.
c. Purpose of Charge: Insert the business purpose for which these
charges were necessary.
d. Amount: Insert the actual amounts paid in registration fees
or other expenses. Attach itemized receipts for reimbursement.
e. Total Registration Fees and Other: Insert the sum of the
Amount column in the Total Registration Fees and Other box.
10. Section D: Business Meals
a. Date of Charge: Insert the date in which the business meals
were paid.
b. Attendees: Insert the name of the individuals attending the
business meal.
c. Purpose of Charge: Insert the business purpose for which this
meal was necessary.
d. Amount: Insert the actual amount paid for the meal.
Attach
itemized receipts for reimbursement.
e. Total Business Meals: Insert the sum of the Amount column
in the Total Business Meals box.
11. Account Number: Insert the department, cost share, general
ledger and type of expense numbers. Also enter the total amount to be
charged to the department. Use the second column if there are two departments
being charged. The shaded area is for business office use only.
12.
Summary
a. Total Section A: Insert the amount from the Total Mileage
box.
b. Total Section B: Insert the amount from the Total Parking Fees
and Tolls box.
c. Total Section C: Insert the amount from the Total Registration
Fees and Other box.
d. Total Section D: Insert the amount from the Total Business Meals
Box.
e. Total Due Traveler: Insert the sum of the Total Section A, Total
Section B, Total Section C and Total Section D. This amount is the total
charges incurred by the traveler, which is being requested for reimbursement.
13. Signatures: The Traveler is required to obtain the signature
of the appropriate Unit Budget Manager and Senior Administrator (if required)
before reimbursement will be issued.
Click here for
COTC AND COST
SHARE LOCAL EXPENSE REIMBURSEMENT REQUEST FORM
Got questions? if yes email Maggie
Snyder, extension 233 or Susan
Spurgeon, extension 234.
