EMPLOYEE EXPENSE FORM
Date entered: SEMA4 ________
Employee Name
ISRS ________ Tran # _________________________
Job Title
Expense Group ID ___________________
Barg Unit Employee ID
Employee Home Address
Cost Centers to Charge: Home Campus:
In-State Out-State Advance
Fund:
Amount:
Cambridge
Coon Rapids
Split
Other
Special Expense form attached? Faculty or Staff Development Form attached? Out-of-State Travel Form attached? Final Expense for this Trip?
Vehicle Time Time Arrive Travel From: Travel To: Control # Trip Miles: Mile Rate * Total (M x R) Meals √ B L D
Meals (no
overnight stay)
CC Totals:
Trip Dates: (Start/End)
Date
Daily Description/Comments
Depart
Meals (overnight stay)
Lodging
Conf / Reg Fee
TOTAL Parking EXPENSE
SUB-TOTAL:
* Mileage rate for Jan '05 - Aug. '05 is .335 or .405, September 05-December 05 .415 and .485, Jan. '06-Dec. '06 is .375 or .445.
If using private car for out-of-state travel: What would lowest airfare to destination be?
I declare under the penalties of perjury that this claim is just and correct and that no part of it has been paid except with respect to those advance amounts shown. I AUTHORIZE PAYROLL DEDUCTION OF ANY SUCH ADVANCES.
OTHER EXPENSES
Type Date Comments Total
State employees and other officials using state funds traveling on state business and using commercial airlines cannot claim frequent flyer mileage as thei own. Employees must certify that they have not claimed frequent flyer mileage for personal use when they apply for travel reimbursement. Any benefits received belong to the State.
Employee Signature Date Work Phone
Approved: Based on knowledge of the necessity for travel and expense and on the basis of compliance with all provisions of applicable travel regulations.
GRAND TOTAL:
Less Advance Total Amount to be Paid to Employee
Total Amount to be Paid by Employee
Supervisor Signature
Date
Work Phone
EMPLOYEE EXPENSE FORM (In-State)
(Completed by Business Office) Date entered: SEMA4 ________
Employee Name
ISRS ________ Tran # _________________________
Job Title Barg Unit
Expense Group ID ___________________
Employee ID
Jane Doe
Employee Home Address
Student Activity Coodinator
MAPE
12345678
1234 XYZ Street, Coon Rapids MN 55008 Home Campus:
In-State Out-State Advance X
Cambridge
Coon Rapids
Split
Other
Cost Centers to Charge: 123456
Fund:
Amount: $450.99
Special Expense form attached? Faculty or Staff Development form attached? Out-of-State Travel form attached? Final Expense for this Trip?
Vehicle
CC Totals:
Trip Dates: (Start/End) 12/13/03-12/15/03
$450.99
Time Date Daily Description/Comments Depart 8:00 AM
Time Arrive 4:30 PM
Travel From: CR
Travel To: Rochester
Control # 123
Trip Mile Rate * Miles: 96 0.375
Total (M x R)
Meals √ B L D x x
Meals (no
overnight stay)
Meals (overnight stay) 24.00
**
Lodging 75.87 75.87
**
Conf / Reg Fee
**
Parking 5.00
TOTAL EXPENSE
12/13/03 Conference in Rochester 12/14/03 Conference in Rochester 12/15/03 Return from Conference
8:00 AM
4:30 PM
Rochester
CR
123
96
0.375
* Mileage rate for Jan '03 - Dec '03 is .29 or .36; Jan '04 - Dec '04 is .305 or .375
SUB-TOTAL:
36.00 0.00 36.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 72.00
100.00
10.00
0.00
24.00
151.74
100.00
15.00
140.87 185.87 36.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 $362.74
If using private car for out-of-state travel: What would lowest airfare to destination be?
# Required for mileage when round-trip distance is 75 miles or greater - Coon Rapids only. Business Office will determine the Type Code.
Type
Date
12/13/03
OTHER EXPENSES Comments
Excel book (prior approval from Dean) (receipt needed)
Total
55.00
** Asterisk items need receipts; some expenses entered under Other Expense column may need receipts
Receipts are not needed for Mileage, Meals, Baggage Handling, Parking Meters
12/22/03 Work Phone
Pizza for student recognition gathering (receipt needed)
33.25
Employee Signature
Date
Approved: Based on knowledge of the necessity for travel and expense and on the basis of compliance with all provisions of applicable travel regulations.
GRAND TOTAL:
Less Advance Total Amount to be Paid to Employee
Total Amount to be Paid by Employee
$450.99
Supervisor Signature
Date
Work Phone
EMPLOYEE EXPENSE FORM (Out-State)
(Completed by Business Office) Date entered: SEMA4 ________
Employee Name
ISRS ________ Tran # _________________________ Expense Group ID ___________________
Job Title Barg Unit Employee ID
John Smith
Employee Home Address
Faculty
MCCFA
87654321
1267 ABC Drive S, Cambridge MN 55008 Home Campus:
In-State Out-State Advance X No
Cambridge
Coon Rapids
Split
Other
Yes
Special Expense form attached? Faculty or Staff Development Form attached? Out-of-State Travel Form attached? Yes Final Expense for this Trip? Yes
Vehicle Control
Cost Centers to Charge: 123456 654321 CC Totals:
Fund:
Amount: $505.13 $200.00 $705.13
Trip Dates: (Start/End)
12/12/03-12/14/03
Time
Time
Travel
Travel
Trip Mile Rate *
0.305
Total
Meals √ ** Conf/Reg Fee
250.00
TOTAL ** Parking
25.00
Date
Daily Description/Comments
Depart
5:30 AM
Arrive
7:00 AM
From:
Camb
To:
Airport
#
Miles:
58
Meals (no Meals overnight (overnight ** Lodging (M x R) B L D stay) stay)
EXPENSE
12/12/03 Conference in Washington 12/13/03 Conference in Washington 12/14/03 Return from Conference
6:00 PM
8:00 PM
Airport
Camb
58
0.305
* Mileage rate for Jan '03 - Dec '03 is .29 or .36; Jan '04 - Dec '04 is .305 or .375
SUB-TOTAL: If using private car for out-of-state travel: What would lowest airfare to destination be?
Business Office will determine the Type Code.
17.69 0.00 17.69 0.00 0.00 0.00 0.00 0.00 0.00 0.00 35.38
x x x
33.00 (pd by conference)
123.75 123.75
x
15.00
15.00
33.00
247.50
250.00
25.00
449.44 123.75 32.69 0.00 0.00 0.00 0.00 0.00 0.00 0.00 $605.88
# Required for mileage when round-trip distance is 75 miles or greater - Coon Rapids only.
Type
Date
12/12/03 12/12/03 12/13/03 12/15/03
OTHER EXPENSES Comments
taxi (receipt not required) Baggage Handling (receipt not required) business phone (requires receipt) taxi (receipt not required)
Total
28.00 10.00 7.68 28.00
**Asterisk items need receipts; some expenses entered under Other Expense column may need receipts
Receipts are not needed for Mileage, meals, Baggage Handling, Parking Meters
Employee Signature
Date
Work Phone
Approved: Based on knowledge of the necessity for travel and expense and on the basis of compliance with all provisions of applicable travel regulations.
GRAND TOTAL:
Less Advance Total Amount to be Paid to Employee Total Amount to be Paid by Employee
$705.13
Supervisor Signature
Date
Work Phone