UNIVERSITY OF VIRGINIA MEDICAL CENTER Travel Budget and Reimbursement Request Form
TRIP INFORMATION
Employee Name (Last, First, M.I.) Employee Home Address City, State, Zip Employee Id Number Department Name Department Phone Number & Address Peoplesoft Department Code to be Charged Departure Date Return Date Name of Meeting/Conference Purpose of Trip Primary Destination (City, State/Country)
PREPAID AND REIMBURSEMENT REQUEST (actuals)
Trip Budget
Public Transportation (i.e., airfare, bus, train)……………………………………………………………………… $ Car rental (include gasoline costs incurred)………………………………………………………………………. Personal Car (mileage) -@ State Rate ……………..Estimated number of miles: @ $0.585 Registration fees………………………………………………………………………………………………………. Parking, Tolls (Please provide detail) Business Phone calls, faxes, etc…… Miscellaneous (Please explain)……. Lodging: City and State or City and Country ↓ Rate ↓ Taxes ↓ # nights ↓ Lodging……………………………...…. Meals: >>>>>>>>>>>>>>>>>>>>>>> Per Diem Meal Rates (in-state & out-of-state) Per Diem (Day of Departure)…………………………………………..………. @ 75% Per Diem FULL DAYS………………………………………………...…..…….. @ 100% Per Diem (Day of Return)………………………………………………..…..… @ 75% Incidentals expense allowance……………...…. Total Nbr of Travel Days @ $3.00 Certified Business Meals (certification form and original receipts required)…………………………………. Additional Expenses (must be fully explained and original receipts attached)…………………………....…. LESS: DEDUCTION FOR MEALS PROVIDED BY THE CONFERENCE/EVENT……………………………… LESS: AMOUNT NOT ALLOWED BY DEPARTMENT……………………………………………………...……… TOTAL BUDGET PREAPPROVAL/REIMBURSEMENT REQUEST……………………………………….....…….. $
BUDGET (estimated)
Pre-Travel Budget Authorization (Complete prior to travel and retain a copy for post-trip processing): Prepared and Submitted by:_________________________________
signature I CERTIFY THAT BUDGET IS AVAILABLE FOR THIS TRAVEL AND THAT THE PROJECTED TRAVEL EXPENSES APPEAR REASONABLE AND NECESSARY FOR THE CONDUCT OF MEDICAL CENTER BUSINESS PER MEDICAL CENTER POLICY 0015.
Date:_____________
Agency Head or Designated Administrator:
Signature Print Name
Date:
Expenditures up to 150% of base limits requires designated administrator's approval in advance of travel. Expenses in excess of 150% of base limits are not allowed from State funds and can only be reimbursed from local funds (see local funds policy 0238).
Post-Travel Reimbursement Authorization (Complete and submit within 5 working days of travel):
I CERTIFY THAT THE REIMBURSEMENT OF THE TRAVEL EXPENSES REQUESTED ABOVE WERE NECESSARY FOR THE CONDUCT OF MEDICAL CENTER BUSINESS AND ARE IN ACCORDANCE WITH MEDICAL CENTER POLICY # 0015. ORIGINAL DOCUMENTATION IS ATTACHED WITH ADDITIONAL COMMENTS RELATED TO UNUSUAL CIRCUMSTANCES, IF ANY.
Traveler Signature: Supervisor Signature: Agency Head or Designee (if required, per policy 0015):
Date: Date: Date:
UNIVERSITY OF VIRGINIA MEDICAL CENTER Travel Continuation Sheet
If trip included more than 1 location, use the worksheet below to show detail for additional amounts to be reimbursed. ADDITIONAL LOCATIONS REIMBURSEMENT
City and State OR City and Country Rate* Taxes # nights
REQUEST (actuals)
Lodging Meals and Incidentals Per Diem Lodging Meals and Incidentals Per Diem Lodging Meals and Incidentals Per Diem Lodging Meals and Incidentals Per Diem Lodging Meals and Incidentals Per Diem
Additional Lodging and M&IE Charges to be Transferred to Reimbursement Claim Form:
* See meal chart for limits. If reimbursing meals from local funds and/or using actual expenses in lieu of M&IE, use the worksheet below to show detail for the meal expenses. ACTUAL MEAL EXPENSES* Day #: 1 2 3 4 5 6 7 Breakfast Lunch Dinner Day Total
Actual Meal Expenses to be Transferred to Reimbursement Claim Form:
8
* See meal chart for limits. FURTHER EXPLANATION / JUSTIFICATION If additional information is required to process this reimbursement request, please provide below:
Total
(This amount will be automatically added to the Total on the Reimbursement Form)
UNIVERSITY OF VIRGINIA MEDICAL CENTER
Business Meal Certification
Meals purchased for others for a bonafide business purpose must be substantiated, and receipts provided to be reimbursed. The traveler's meals must still be reimbursed as part of the M&IE allowance. Business meals must meet the M&IE per meal rate for the city in which the meal is purchased. Please complete the information below for each business meal being reimbursed:
Explain Business Purpose of Meal: Location of Meal
Date
Meal Amount*
Name(s) of other meal participant(s)
Employer/Affiliation
Explain Business Purpose of Meal: Location of Meal
Date
Meal Amount*
Name(s) of other meal participant(s)
Employer/Affiliation
Explain Business Purpose of Meal: Location of Meal
Date
Meal Amount*
Name(s) of other meal participant(s)
Employer/Affiliation
Explain Business Purpose of Meal: Location of Meal
Date
Meal Amount*
Name(s) of other meal participant(s)
Employer/Affiliation
Explain Business Purpose of Meal: Location of Meal
Date
Meal Amount*
Name(s) of other meal participant(s)
Employer/Affiliation
TOTAL BUSINESS MEALS (This amount will be automatically added to the Claim Form.) * Enter the amount that is being requested for reimbursement. See meal chart for allowable amounts. Must attach original itemized receipt(s) to this form and send to Invoice Processing, P.O. Box 800779.
Travel Form 4/20/00
UNIVERSITY OF VIRGINIA MEDICAL CENTER
Meals Provided Deduction
Meals provided as part of the cost of the conference or paid for by others, must be deducted from the Meals and Incidental Expense (M&IE) allowance. PLEASE NOTE: a continental breakfast is considered to be a meal and, therefore, should not be deducted from your total reimbursement. Please use the worksheet below to calculate your deduction:
DAY OF DEPARTURE AND/OR RETURN ONLY
Meal Type Breakfast Lunch Dinner
# of meals $ Amount * Total
Multiplied by 75%
.75
Amount to be Deducted
FULL DAYS
Destinations with $39.00 M&IE Rate Meal Type Breakfast Lunch Dinner
# of meals $ Amount $ 7.00 $ 11.00 $ 18.00 Total
Destinations with $44.00 M&IE Rate Meal Type Breakfast Lunch Dinner
# of meals $ Amount $ 8.00 $ 12.00 $ 21.00 Total
Amount to be Deducted Destinations with $49.00 M&IE Rate Meal Type Breakfast Lunch Dinner
# of meals $ Amount $ 9.00 $ 13.00 $ 24.00 Total
Amount to be Deducted Destinations with $54.00 M&IE Rate Meal Type Breakfast Lunch Dinner
# of meals $ Amount $ 10.00 $ 15.00 $ 26.00 Total
Amount to be Deducted Destinations with $59.00 M&IE Rate Enter Total Daily Per Diem Allowed: Meal Type # of meals $ Amount Total Breakfast $ 10.00 Lunch $ 15.00 Dinner $ 26.00 Amount to be Deducted Foreign Destination 1 Enter Total Daily Per Diem Allowed: Meal Type # of meals $ Amount Breakfast Lunch Dinner Amount to be Deducted
Amount to be Deducted Destinations with $64.00 M&IE Rate Enter Total Daily Per Diem Allowed: Meal Type # of meals $ Amount Total Breakfast $12.00 Lunch $18.00 Dinner $31.00 Amount to be Deducted Foreign Destination 2 Enter Total Daily Per Diem Allowed: Meal Type # of meals $ Amount Breakfast Lunch Dinner Amount to be Deducted
Total
Total
TOTAL TO BE DEDUCTED FROM REIMBURSEMENT
* See meal chart for limits.
Travel Form 4/20/00