Back Charge Letter to Contractor - Excel

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Back Charge Letter to Contractor - Excel Powered By Docstoc
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                                                                                 Texas A&M Agriculture                                            1
                                                                                           Travel Voucher
     The State of Texas                                                                                                                           2        E-
     Comptroller
     of Public 73-174                          3                                  4                                               5                                                       AG-801
     Accounts (9-99/5)                                                                                                                                                                      D-187
Archive reference number                           1. Agency number               2. Agency name                                                                     Current document number

                                                   Effective date                     DOC date           Doc agency        PDT          3. Document amount
                                                                                                                                                           $0.00     1
4. Pay to: (Name, address, city, state, ZIP code)                                                   Invoice Date                      5. Title
                                                                                                                           7
         6                                                                                          Invoice Number                    6. Designated Headquarters
                                                                                                                           8
                                                                                                    Invoice Rec'd Date                7. Account No.                           8. T & L #
                                                                                                                           9                                             10
9. Payee Identification Number                                                                      Requested Pymt Date               10. Department Name                      11. Dept. VO #
       11                                                                                                                  12                                            13    E- 0
 12. S-ACCT/PROJ                    13. OBJ. CLASS                     BANK               14. AMOUNT               12. S-ACCT/PROJ         13. OBJ. CLASS           BANK         14. AMOUNT
             14                                 15                                                  16                    14                          15                                  16




Service Dates    (Order/Delivery Date)                                                                         17. Destination
15. From:     17                                                    16. To:               18                                          19

18. DISTRIBUTION                                                                                                                                                                   AMOUNT
      Expense itemization for in-state travel                                      20
      Fares, Public transportation (Attach receipts): Taxi                                                     Air fare                          Rental Car                       20.a          0.00
      Personal Car Mileage                                                Miles @                              (Rate set by Legislature)                                          20.b          0.00
      Meals and/or lodging                                   0.00                                                                                                                 20.c          0.00
      Parking                                           Toll Fees                                            Other:                                                               20.d          0.00
      Other travel expenses (itemize)                         Hotel Tax                                       Other:                                                              20.e          0.00
      Business Calls                                             Registration                                 Other:                                                              20.f          0.00
      Expense itemization for out-of-state travel                                              21
      Fares, Public transportation (Attach receipts): Taxi                                                     Air fare                          Rental Car                      21.a           0.00
      Personal Car Mileage                                                Miles @                              (Rate set by Legislature)                                         21.b           0.00
      Meals and/or lodging                                   0.00                                                                                                                21.c           0.00
      Parking                                           Toll Fees                                            Other:                                                              21.d           0.00
      Other travel expenses (itemize)                         Hotel Tax                                       Other:                                                             21.e           0.00
      Business Calls                                             Registration                                 Other:                                                              21.f          0.00
NOTE: Employee to keep extra copy for income tax purposes. Do not charge such items as miscellaneous incidentals or unauthorized
                                                                                                                                                                   TOTAL          22
expenses as they will not be approved by the Comptroller.                                                                                                                                       0.00
The following exception(s) is(are) being claimed for the use of non-contracted vendors.
A=Airline L =Lodging C=Car Rental


                       1. Part of Group                                                                                          4. Health and Safety Issues
    23                 2. Lower Total Cost
                       3. Efficient Use of Service. Circle Approriate Letter
                           Contractor Not Time Efficient
                           Contractor Not Available
                           Contractor Sold Out
ADVANCE RECEIVED $
I certify that the expense account shown above is true, correct, and
unpaid.
                 24



Claimant Signature
                                   25
                                                                               Date
                                                                                                               AGENCY APPROVAL -
                                                                                                               Date approved for payment


                                                                                                               Name

                                                                                                               Name
                                                                                                                           27            A C
                                                                                                                                        AL YES
                                                                                                                                        LANO L
                                                                                                                                        C L            26                          , 20



                                                                                                                                                                                Department Head

                                                                                                                                                                               Fiscal Officer
                                          28
         Contact Name                                                                           Phone No.                                                          Mail Stop
                                           White - Fiscal Copy                                 Yellow - Department Copy                    Blue - Vendor Copy
Form 73-174 (Back)(9-99/5)                                                                                                                                            AG-801



IN-STATE                                                                                                                                   ACTUAL EXPENSE
        a. Leave Headquarters               b. Arrive Headquarters        c.        d. Actual meals   e. Actual lodging      f. TOTAL       g. Meals   h. Lodging     l. TOTAL
 Date         Hour    Min.      m.   Date       Hour       Min.      m.              not to exceed      not to exceed      not to exceed
                                                                                          $36                $85                $121
                                                                                                                          33                                          36
  29                                 30                                                  31                32                  0.00          34           35           0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                  37                                             38
                                                                                                                               0.00                                    0.00
                                                                          j.        TOTAL MEALS & LODGING                      0.00        TOTAL ACTUAL EXPENSE          0.00

OUT-OF-STATE                                                                                                                               ACTUAL EXPENSE
        m. Leave Headquarters               n. Arrive Headquarters        o.        p. Actual meals   q. Actual lodging     r. TOTAL        s. Meals    t. Lodging    u. TOTAL
 Date         Hour    Min.      m.   Date       Hour       Min.      m.                  up to              up to              up to
                                                                                     Federal Rate       Federal Rate       Federal Rate
                                                                                                                          43                                          46
  39                                 40                                                  41                42                  0.00          44          45            0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                               0.00                                    0.00
                                                                                                                47                                              48
                                                                                                                               0.00                                    0.00
                                                                          v.        TOTAL MEALS & LODGING                      0.00        TOTAL ACTUAL EXPENSE          0.00

                                                                                                                                                          MILEAGE
         DATE                                   y. RECORD OF TRANSPORTATION AND DUTIES PERFORMED
                                                                                                                                                       POINT TO POINT*



         49                                                                    50
                                                                                                                                                               51




                                                                                                                                                         TOTAL 52
                                                         Use additional form or a "CONTINUATION SHEET" if additional space is needed.
                                                        * Show point-to-point breakdown, including intra-city mileage claims.




                                                                                      53
Form 73-174 (Back)(9-99/5)                                                                                                                                    AG-801



IN-STATE                                                                                                                             ACTUAL EXPENSE
        a. Leave Headquarters               b. Arrive Headquarters        c.   d. Actual meals   e. Actual lodging     f. TOTAL       g. Meals   h. Lodging   l. TOTAL
 Date       Hour      Min.      m.   Date       Hour       Min.      m.         not to exceed      not to exceed     not to exceed
                                                                                     $36                $85               $121

                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                                                                        0.00                                   0.00
                                                                          v.   TOTAL MEALS & LODGING                    0.00         TOTAL ACTUAL EXPENSE       0.00




                                                                                   54

Form 73-174 (Back)(9-99/5)                                                                                                                                    AG-801



OUT-OF-STATE                                                                                                                         ACTUAL EXPENSE
OUT-OF-STATE                                                                                                                           ACTUAL EXPENSE
        m. Leave Headquarters               n. Arrive Headquarters        o.      p. Actual meals   q. Actual lodging    r. TOTAL       s. Meals    t. Lodging       u. TOTAL
 Date       Hour      Min.      m.   Date       Hour       Min.      m.                up to              up to             up to
                                                                                   Federal Rate       Federal Rate      Federal Rate

                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                                                                           0.00                                       0.00
                                                                          v.      TOTAL MEALS & LODGING                    0.00        TOTAL ACTUAL EXPENSE           0.00




                                                                                       55

                                                                               CONTINUATION SHEET
                                                                                                                                                                 AG-801

                                                                                                                                                      MILEAGE
         DATE                                   y. RECORD OF TRANSPORTATION AND DUTIES PERFORMED
                                                                                                                                                   POINT TO POINT*
                                                                                TOTAL 52

 Use additional form or a "CONTINUATION SHEET" if additional space is needed.
* Show point-to-point breakdown, including intra-city mileage claims.

				
DOCUMENT INFO
Description: Back Charge Letter to Contractor document sample