DOMESTIC TRAVEL REIMBURSEMENT CLAIM FORM

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DOMESTIC TRAVEL REIMBURSEMENT CLAIM FORM

Form and receipts must be submitted within 45 days of completion of travel
If we have questions who should we contact? Payee Preparer Other
Preparer's Name:
(Fill only if other than payee)


Phone:
Email:
Dept.:
If other than the Payee or Preparer, enter Preferred Contact info:

Name:
Phone:
Email:
PAYEE
Name: (Last, First)
Phone:
Email:
City of Res.:
UCB Employee
UCB Student
Other

Emp/Stu/Ven ID:
If not currently a vendor, you will be contacted by CSS for more information
Org Node:
Dept.:
US Citizen/Permanent Resident? Yes No
If no, you will be contacted by CSS for more information (Passport, I-94,UC-W-8BEN, COAA)
TRIP
Business Purpose:
Details for any Personal Time, Entertainment or Special Circumstances: Enter date(s), location(s). For entertainment, also include business purpose, guest names & their affiliation. Enter meal costs in M&IE section blw.
Destinations:
Depart: Home
Office
Date:
Time: a.m. p.m.
Return: Home
Office
Date:
Time: a.m. p.m.
PRIVATE CAR    Personal Automobile Used?    
Most direct route is reimbursable. For expenses incurred on or after January 1, 2017 the reimbursement rate for the use of a private automobile for University business travel decreased from 54.0 cents a mile to 53.5 cents a mile. 53.5 cents is the default rate on the form. If other, override default rate with appropriate rate used for your program BEFORE entering mileage. See instructions
AIR       Air Expenses? (Attach itinerary, showing proof of payment)
OTHER TRANSPORT    Other Transportation Used? (Bart, Shuttle, Taxi, Etc.)
OTHER EXPENSES       Other Misc. Expenses? (Gas, Tolls, Phone, Internet, Baggage, Etc.)
DAILY EXPENSES       Daily Expenses? (Lodging, Meals & Incidentals, Etc.)
         ESTIMATED TOTAL EXPENSES $0.00
Reductions:1.     Travel Advance? Yes No         Attach original request Amount Reduction
Amount
Enter amount as negative numbers                 2.Other Reductions?         
$-0.00
       ESTIMATED TOTAL REIMBURSEMENT NOT TO EXCEED       $0.00
COA
BU ACCOUNT FUND DEPT. ID PGM CF1 CF2 AMOUNT
Check If You Need Additional COA
OPTIONAL: Chartstring Description
(Department specific)

OPTIONAL: Accounting Approval
(Department specific)
CERTIFICATION
I certify that the above is a true statement, that the expenses claimed were incurred by me on official University business on the date shown, and that I have attached original receipts for each expense of $75 or more, as required by University policy.
Traveler's Signature:
Name:
Title:
Date:

I authorize these expenditures and approve this claim to be submitted for review of University policy compliance.
Authorizer's Signature:
Name:
Title:
Date:

Exceptional Signature:
Name:
Title:
Date:


5/11/2015