OFFICIAL VISIT - Exhibit J Page 1 of 2
Name: Sport: Start Date: Start Time:
Empid: Event / Purpose: End Date: End Time:
Location: Location:
Meals and Incidentals (list each receipt including tip) Lodging List Each Hotel
Date Resturant Name Meal P-Card Cash Dates Lodging Name P-Card Cash Direct Bill
TOTALS $ - $ - $ - $ -
Public Transportation (Air, Taxi, Bus)
Dates Name of Company P-Card Cash Direct Bill
TOTALS $ - $ - $ -
TOTALS $ - $ - $ - $ -
Mileage from PSA Reimbursement form (Staff use Regular Exhibit J)
Dates Name PSA or Family Exhibit J Cash Owed PSA
Rental Cars
Dates Name of Company P-Card Cash Direct Bill
TOTALS $ - $ - $ - $ -
Miscellaneous (host money, parking, entry fee, etc)
Dates Name of Host/Company P-Card Cash Direct Bill
TOTALS $ - $ - $ - $ -
Fuel
Dates Name of Company P-Card Cash Direct Bill
TOTALS $ - $ - $ - $ - TOTALS $ - $ - $ - $ -
OFFICIAL VISIT - Exhibit J Page 2 of 2
Summary of Expenses Business Office Use Only P-cards used
Total OFV cost: $ - GAE# Name & last 4 #'s on Pcard
Advance Amount: $ - TA#
P-Card: $ - TP # ____________________________________
Direct Bill /Owed/Exhibit J $ - PD #____________________________________
Cash: $ - PD #____________________________________
Due to Employee/ (NAU): $ - IET #____________________________________ Others Due Reimbursement
( ) indicate amount owed to NAU IET #____________________________________ Name & Amount
COACHES CERTIFICATION
I certify that the items of expense in this claim were incurred for authorized official state business and that they
are correct and proper charges. If this travel claim involves travel by vehicle, I certify that I have a valid Arizona
driver's license, and if a personal vehicle was used, I certify that the vehicle has liability insurance coverage. PSA Names
I further certify that any third party payments or reimbursements are disclosed on this form. If I am overpaid or
fail to settle my account in full I authorize NAU to deduct the balance against my wages (ARS 35-195.02B)
I UNDERSTAND THAT FILING A FALSE CLAIM IS A FELONY.
Coaches Signature: Date:
SUPERVISOR CERTIFICATION
I certify that this trip was authorized by me and that the trip was necessary and appropriate for this employee's
job duties in his/her conduct of official Arizona state business. I further certify that, to the best of my
knowledge, the items of expense in this claim, are correct and proper charges.
Supervisor Signature: Date:
AUTHORIZED ACCOUNTING SPECIALIST CERTIFICATION
I certify that I have reviewed this claim, matched the amounts claimed to the supporting documentations
attached and that the claim is prepared in compliance with NAU/DOA travel policy and procedures.
Accounting Specialist Signature: Date:
Compliance Signature: Date:
Sport Supervisor Signature: Date:
Athletics Director Signature: Date: