MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
MONTH
DOCUMENT NO.
VENDOR NO. (SOCIAL SECURITY NO.)
MONTHLY EXPENSE REPORT
EMPLOYEE NAME (LAST, FIRST)
DIRECT (ACH) AGENCY (CHECK) HOME (CHECK)
PAGE
OF
HOME ADDRESS (Only needed if HOME (CHECK) is marked)
DEPARTMENT/DIVISION OR INSTITUTION
OFFICE ADDRESS
WORK PHONE NO.
UNIT/COUNTY
DATE
FROM/TO & PURPOSE
RET (X)
TRAVEL OPTION**
R A T E
MILES
BREAKFAST
LUNCH
DINNER
LODGING
BUS/R.R./ AIR - CAR RNTL EXP.
MISC.*
TOTAL
TOTALS FROM OTHER PAGES
» » TOTAL STANDARD (S) MILES » TOTAL FLEET (F) MILES » TOTAL RENTAL (R) MILES »
TOTALS OF ABOVE
TOTAL OUTSTATE
AT AT AT
$0.500 $0.260
PER MILE PER MILE PER MILE
TOTAL INSTATE
$
DATE
$ * EXPLANATION OF MISCELLANEOUS
TOTAL REIMBURSABLE EXPENSE
»
** EXPLANATION OF TRAVEL OPTION (Choose all that apply for each trip) 1 DHSS VEHICLE NOT AVAILABLE 2 RENTAL VEHICLE NOT AVAILABLE 3 PROXIMITY OF STATE VEHICLE 4 PROXIMITY OF RENTAL VEHICLE 5 EMERGENCY/ANONYMITY (explain) 6 DHSS THRESHOLD OPTION 7 (a-e) EXCEPTIONS (refer to policy)
I hereby certify the above claim is correct, that these expenses were necessary to conduct state business, that payment has been made from personal funds for which I have not been reimbursed, nor will I receive from any source any payment for these expenses.
CLAIMANT SIGNATURE DATE
I hereby certify that I have reviewed the above claim and that the expenses are accurate and in compliance with DHSS and OA Policy.
APPROVAL SIGNATURE
APPROVAL NAME (PLEASE PRINT OR TYPE)
CLAIMANT NAME (PLEASE PRINT OR TYPE)
TITLE
DATE APPRVD
TITLE
OFFICIAL DOMICILE
VERIFIED BY
DATE
MO 580-2347E (06-09)
DISTRIBUTION: WHITE/DIVISION OF ADMINISTRATION
CANARY/DIVISION-CENTER
PINK/EMPLOYEE RETAINED
DH-57
DOCUMENT NUMBER
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
EMPLOYEE NAME
MONTH
YEAR
MONTHLY EXPENSE REPORT CODING DETAIL ACCOUNTING DISTRIBUTION
2100-06 2100-07 2103 2104 2106
20
OBJECT CODE DETAIL AMOUNT
2109 2112 2115-06 2115-07 2118 2119 2121 2124 2127 Misc. Object Out-Of- Code/SubMisc. Object State Expense Travel Exp. Code (if (Other) applicable ) Out-OfState In-State Mileage Travel Exp. (Standard (Other) Mileage Rate) Out-OfOut-OfOut-OfState State State Mileage Commercia Commercia (Reduced l Transp.l Transp.Mileage Travel Other Rate) Agency
FUND
ORG
APPR
ACTIVITY
In-State FUNCTIO JOB/ REP CAT Mileage N PROJECT (Standard Mileage Rate)
In-State In-State In-State Mileage Commercia Commercia (Reduced l Transp.l Transp.Mileage Travel Other Rate) Agency
In-State Lodging
In-State Meals
Out-OfState Lodging
Out-OfState Meals
TOTALS
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 TOTALS
MO 580-2348E (4-09)
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
DH-58
TOTAL EXPENSES
DISTRIBUTION: WHITE/FINANCIAL SERVICES CANARY/PROGRAM
Allowable threshold whereby an employee may request the standard mileage reimbursement when a DHSS vehicle is not available. # of days for a single trip # of miles for a single trip 1 day trip <= 185 miles 2 day trip <= 300 miles 3 day trip <= 400 miles 4 day trip <= 500 miles 5 day trip <= 600 miles
NOTE: Thresholds are subject to change. Employees will be notified prior to any changes to the allowable thresholds.
01/16/07
Travel Options Flow Chart Refer to Financial Policy 1.3 - Reimburseable Travel Expense and Monthly Expense Report Section IV D for more information.
Travel Options
Yes
Yes
Is the proximity to a DHSS vehicle reasonable? No
No
Is a DHSS vehicle available?
Take DHSS vehicle If a personal vehicl is driven, mileage reimbursement is a the state fleet rate
Yes
Is No the trip within
DHSS threshold amount?
Standard mileage reimbursement is
Yes
Yes
No
No
Is the proximity to a rental vehicle reasonable?
Is a rental vehicle available?
01/16/07