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Travel Reimbursement Form

Used for all travel reimbursement; same day, in-state, overnight or out-of-state.

Traveler's Name:
Account Name:
Account Number:
CWID (Campus Wide)
Number:
- -
Origination & Destination:
Official Business:
Date/Time of Departure:
Date/Time of Return:

Verification Forms & Receipts

Lodging
Send verification forms & receipts via intercampus mail.
Designated Hotel Statement: Yes   No
Single Room Rate Verification: Yes   No
Original Hotel Receipt with Zero Balance: Yes   No
Hotel amount total:
Registration Fee paid by:
Send verification forms & receipts via intercampus mail.
Purchase Order: Yes   No
ProCard: Yes   No
Traveler: Yes   No
Registration amount total:
Miscellaneous costs
Send verification forms & receipts via intercampus mail.
Mileage
Automobile Tag # (only if using your own car)
Parking
Tolls
Transportation (Taxi, Shuttle, etc.)
Miscellaneous Fees (Fax, etc.)
Other (specify)
Miscellaneous costs total
TOTAL AMOUNT CLAIMED
Per Diem (this amount will be calculated by the Travel coordinator and combined with the amount claimed after this form is submitted)
Official Business Agenda: Yes   No
Number of Meals Provided:
Submitted By:
(Name & Department)

Note: If actual expenses are $50 or more over the total estimated expenses on the 'Out of State Travel Request and Airline Requisition Form' you filled out before the trip, you must provide a memo from your department head explaining the overage.

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