Mileage Claim

							                                                        MILEAGE CLAIM
                CALIFORNIA STATE UNIVERSITY, LONG BEACH FOUNDATION - (562) 985-5430                                                                   Vendor#
ARE YOU A FIRST TIME PAYEE? IF SO, COMPLETE SUBSTITUTE W-9 FORM                   W-9 Form:
AND RETURN IT TO ACCOUNTS PAYABLE BEFORE PAYMENT WILL BE MADE.                ON FILE    ATTACHED


Name:                                                        Employed as:                                                    Check to be distributed as follows:
Home Address:                                                Office at:                                                           US Mail
City, State, Zip:                                            Distance Between Home and Office                  miles              Payee /Dept Staff Pick-up

Social Security# (last 4 digits):                                                                                                                                     NAME
( if new payee, submit W-9 form to AP before payment will be made)

                                                                                                                                                                Payee’s
                                                                                                                                  ACH Payment*                  Extension
                                                                                                                             *ACH Direct Payment Authorization must be on
Month Covered by Claim           Project # (8 digits)        G/L Line Item # (6 digits)            Dept. Ref #               file with the Foundation 12 days prior to first
                                                                                                                             payment.


                           Start               Destination      Name of Destination                   Purpose of Trip                         Odometer              Total Miles
        Date              Address               Address           Ex. Hyatt Hotel         Ex. To attend CDC’s Director’s Meeting               Reading               Claimed




                                                               Current Federal Rate                                                      Total Miles:
                                                               Cents/Mile: .50                   Amount Claimed for Mileage (Miles x Current Rate)*:
                                                                                                      Amount Claimed for Attached Parking Receipt:
                                                                                                          Total Amount Claimed for Reimbursement:
Signature of Claimant                      Date                                               *(certain grants or contracts may limit the reimbursement rate)

                                                                                                                                         Foundation Use Only

Signature of Approving Officer             Date
                                                                                                                      AP Tech                        Allowability
                                                                                                                                          Date                              Date
                                                                                                                      Approval                       Approval
AP013                                                                                                                                                           Jan. 2010
                                                                           INSTRUCTIONS
                                                                           MILEAGE CLAIM
                                                  CALIFORNIA STATE UNIVERSITY, LONG BEACH FOUNDATION
                                                                     (562) 985-5430

Please print or type the following:

NAME - The full name of the payee.

EMPLOYED AS - Title of the payee.

HOME ADDRESS, CITY, STATE AND ZIP - Mailing Address of the payee.

OFFICE AT - Location where employee normally works.

DISTANCE BETWEEN HOME AND OFFICE - Total miles, one way.

SOCIAL SECURITY NUMBER - Please provide the last 4 digits of payee’s Social Security Number. If a first time payee, complete and submit a Substitute W-9 form to Accounts
Payable before payment will be made. The form may be downloaded from our website, (www.foundation.csulb.edu), and click on forms. No check made payable to an individual
can be issued without a Social Security Number.

MONTH COVERED BY CLAIM - Month trips occurred. Normally a mileage claim should be made for one month.

PROJECT #, G/L LINE ITEM # - Provide the project number being charged. Provide the Line Item General Ledger Account Number being charged within the project (see Chart of
Accounts). The last two digits of the G/L Line Item Number are designated by the Foundation as zero; however, the Project may make arrangements with the Foundation to use
these numbers to define expenses for tracking purposes.

DEPT. REF. # - This reference number is supplied by the project to simplify reconciliation of monthly reports. The Foundation will key in this number when paying the request.
The number will appear on the transaction’s reference line on the monthly report.

DATE - Date of travel.

START ADDRESS – Actual street address of point of origin. Include City and State, if relevant.

DESTINATION ADDRESS – Actual street address of point of destination. Include City and State, if relevant.

NAME OF DESTINATION - Describe a destinations for travel ie, Hyatt Hotel

PURPOSE OF TRIP – Description of why travel is necessary ie, to attend CDC’s Director’s Meeting

ODOMETER READING - Beginning and Ending Odometer reading.

MILES CLAIMED - Total number of miles traveled, round trip, for each destination.

TOTAL MILES - Total miles for all days submitted on claim form.

AMOUNT CLAIMED - Total amount of miles x amount allowed by project. As of 1/1/2010 the mileage reimbursement rate is $0.50 per mile. Certain grants or contracts
guidelines are restricted and may limit reimbursement to a lower rate. Please contact your Grants & Contracts Administrator for verification.

SIGNATURE AND DATE OF CLAIMANT - Signature of Payee and date signed.

SIGNATURE AND DATE OF APPROVING OFFICER - Signature of person authorizing payment for the mileage claim from the designated project and date approval was obtained


AP013                                                                                                                                                          Jan. 2010