Is Individual a UMCP Employee On UMCP Payroll? (Y/N) : Yes
UNIVERSITY OF MARYLAND COLLEGE PARK EXPENSE STATEMENT
First Name & Middle Initial
Date:
April 7, 2009
FAS Account
Social Security No*
Last Name
* Social Security No. Must Be Provided. If Not Applicable, Please provide immigration status with Visa and Passport Number DEDUCTION CODE TR
HOME ADDRESS:
OUT-OF-STATE REQUEST NO. D/DE 86
Street/Apt #
MILEAGE @ 1/2 RATE
SUBCODE MILEAGE @ FULL RATE
AMOUNT IDENT
0
City
0
$
State Zip
PURPOSE OF TRAVEL:
TRAVEL EXPENSES BY DATE DATE (MM/DD/YYYY) BREAKFAST** LUNCH** DINNER** LODGING* TAXI OR LIMO* AIR/RAIL/BUS* AUTO RENTAL* PARKING FEE* BRIDGE OR TOLLS* TELEPHONE* REGISTRATION FEE* PORTERAGE
TOTAL
MEAL COST INCLUDES RELATED GRATUITIES
PRIVATE AUTO MILEAGE
-
miles at
$
0.550
TOTAL EXPENSE
* ORIGINAL RECEIPTS MUST BE OBTAINED FOR EXPENSES NOT COVERED THROUGH PER DIEM ** RECEIPTS REQUESTED AND MUST BE PROVIDED WHEN EXCEEDING PER DIEM
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
-
ITINERARY
DATE (MM/DD/YYYY) TIME FROM: TO: TO: TO: AUTO MILEAGE
ARE ADDITIONAL MEMOS ATTACHED? (Y/N)
Yes/No START-END START | END START END START END START END START END START END
TOTAL
0
No DATE: TRAVELER'S SIGNATURE
CERTIFIED JUST AND CORRECT AND PAYMENT NOT RECEIVED : TRAVEL IN FULL COMPLIANCE WITH POLICY PLEASE PRINT APPROVING AUTHORITY NAME & TITLE . . . . . . : APPROVING AUTHORITY SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . : DEPARTMENT NAME & CONTACT PERSON . . . . . . . . . . . . . . . . . :
DATE:
PHONE . . . . . . :
E-MAIL . . :
FOR QUESTIONS ABOUT THIS TEMPLATE: CONTACT REGION II COMPUTER SPECIALIST at (301) 403-4150 or DR114@UMAIL.UMD.EDU
DEPARTMENT RETAINS A COPY