TA (PERM) Travel Advance Permanent In-State by HC120701201218

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                                                          STATE OF IOWA                                                    TA (PERM)
OFFICIAL DOMICILE
                                                         PERMANENT IN-STATE                                 DOCUMENT NUMBER
                                                      TRAVEL ADVANCE
DATE OF EMPLOYMENT                                                                                       APPROVAL (SUPERVISOR’S SIGNATURE)


NAME AND HOME ADDRESS                                                       ALTERNATE ADDRESS




Out-of-Pocket In-State Travel expenses for the preceding twelve                                        Summary Information
months have been:
  January                                July
 February                            August                                              Prior twelve month total                            0.00
    March                         September
      April                         October                                                     Average per month                            0.00
       May                        November
      June                        December                                                      Authorized amount                            0.00

                                                                 IMPORTANT
       Employees whose In-State Travel Expense has averaged between $100 and $150 per month for the preceding twelve
        months shall receive a Permanent Travel Allowance of $100.
       Employees whose In-State Travel Expense has averaged over $150 per month for the preceding twelve months shall
        receive a Permanent Travel Allowance of $150.

       I hereby give the DAS-SAE authority to deduct this Permanent In-State Travel Advance from my
        paycheck upon separation from State Employment or when I am no longer eligible due to a change
        in duties or job assignment.

       I also give the DAS-SAE and my employing Department the authority to review my monthly travel
        expense and determine if I still meet the requirements pertinent to receiving an In-State Travel
        Advance. Should I fail to meet these requirements, this Advance Travel Allowance shall be
        withdrawn and deducted from my next paycheck, following proper notification.

       Submit appropriate documents to Payroll
                                  CLAIMANT’S CERTIFICATION                                        DEPARTMENT CERTIFICATION
I CERTIFY I HAVE READ THE ABOVE AND AM AWARE OF THE RULES                           I CERTIFY THAT THE ABOVE EXPENSES WERE INCURRED
GOVERNING MY PERMANENT IN-STATE TRAVEL ADVANCE.                                     AND THE AMOUNTS ARE CORRECT AND SHOULD BE PAID
                                                                                    FROM THE FUNDS APPROPRIATED BY:
Employee Vendor #:                             DIRECT DEPOSIT?   WARRANT TO ALT     CODE OR CHAPTER SECTION(S)
                                                 Y      N        ADDR? Y   N
TITLE



CLAIMANT’S SIGNATURE                                               DATE




                                                                                  DOCUMENT TOTAL

TA (PERM)                                WARRANT #                                                               PAID DATE ___________

								
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