DPSST TRAVEL EXPENSE DETAIL SHEET / Part-Time Trainers, Board Members, Volunteers, Agency Loan & Other Travelers
State of Oregon
1a. Name of Traveler 1b. Traveler ID#, if known 2. Agency ID 3. Reimb Period
(Last Name, First Name) (do not use SSN) DPSST / 25900 (Mo & Yr)
1c. Home Address 1d. Mailing Address (if different than Home)
4. Official Work Station 5. Assigned Program 6. Regular Schedule Work Shift
7. Representation: Part-Time Trainer Unrepresented Volunteer Agency Loan Board Member 8 am-5 pm or Other
8. 9. Time of 10. Time of 11. Destination PCA/ Project 12. Per Breakfast Lunch Dinner 13. Lodging 14. Total
Date Departure Arrival (From / To) Code Diem 25% 25% 50% (less tax) Meals & Ldging
15. TOTAL Columns - - - - -
16. 17. MISCELLANEOUS EXPENSES 18. 20. Rate/mi
Travel 19. POV 4/17/12 Forward 21.
Date Fares, (POV) Private Mileage, Lodging Tax, Telephone, Other Expenses PCA/Project Code Mileage $0.51 $0.555 Amount
X POV Form Statement: No state owned / operated Vehicle is available 22. TOTAL Column 21 -
Completion of Section 24 is mandatory. Travel expense reimbursement claims will not be processed if this block is left blank. Travel awards included, but may not be limited to, airline
frequent flyer miles and hotel or car rental frequent customer awards. For information regarding State's Policy on Travel see OAM 40.10.00.PO 23. AMOUNT DUE Traveler $ -
24. I did did not accept travel awards as a result of, or associated with this state business trip.
25. REASON FOR TRAVEL This Section Must be Completed (include dates)
26. I have Received Training Conducted Training
27. Signature of Traveler 28. Title 29. Date
I certify that all reimbursements claimed reflect actual duty required expenses or allowances entitled; that no part
thereof has been heretofore claimed or will be claimed from any other source.
30. Signature of Manager 31. Title 32. Date
I certify that all the above claimed expenses are authorized duty required expenses. Funds for payment of this claim
are available in the approved budget for the period covered and have been allotted for expenditure.
Travel Reimbursement APT Board Member Form 505e (ref 75.40.01.FO) Rev. 04/17/2012