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Travel Expense Statement - Georgia State University

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					                                                                      Georgia State University
                                                                 Travel Expense Statement


Name of Traveler                                                                         Travel Auth/Voucher Number
Address                                                                                  Title
                                                                                         Department
                                                                                         Phone
City, State, Zip                                                                         Panther Card ID #(Vendor#)
Date & Time Departed                                                                     Date & Time Returned
                                                                    DAILY EXPENSES & PER DIEM
Date               Location / Point   Lodging (attach    Max Breakfast          Max Lunch                Max Dinner             Total Meal Per        Lodging & Total          For Disb Use
                   Visited            receipt)           Per Diem               Per Diem                 Per Diem               Diem                  Meal Per Diem            Only
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $             -    $               -      $                 -      $              -       $              -      $          -
                                       $            -                                                                            $              -      $          -
                                                                     MISCELLANEOUS EXPENSES
Date               Misc. Expense:     Parking            Tolls                  Tips for                 Tips for Lodging Carrier/Taxi     Other: Please                       Total
                   Please Explain                                               Transportation                            Shuttl - Attach  Explain
                                                                                                                          Receipt for >$25

                    $           -      $            -     $               -      $                 -      $              -       $              -       $              -        $          -
                    $           -      $            -     $               -      $                 -      $              -       $              -       $              -        $          -
                    $           -      $            -     $               -      $                 -      $              -       $              -       $              -        $          -
Notes:                                                                                                                                                                          $          -
                                                 MILEAGE RECORD (Personally owned automobile and aircraft)
Date                          Points Visited                                                      Odometer                              Miles traveled
                   From              To                                         Starting                 Ending              Total      Personal                               State Use
                                                                                                       0                  0           0                                    0                    0
                                                                                                       0                  0           0                                    0                    0
                                                                                                       0                  0           0                                    0                    0
                                                                                                       0                  0           0                                    0                    0
                                                                                                       0                  0           0                                    0                    0
                                                                                                       0                  0           0                                    0                    0
Total Miles Traveled for State Purpose (Odometer readings required; MapQuest.com mileage may be provided if readings are unavailable)                                                           0
Please note that transportation outside of the state will be by common carrier unless specifically authorized in advance of the trip.
Purpose of the trip                                                              Notes



                                                                 SUMMARY & SWORN STATEMENT
Summary of Reimbursement:                                               Statement & Signature of Traveler:
Total Food                                                $          -  I do solemnly swear, under criminal felony penalty for false statements subject to punishment by a fine of
Total Lodging                                             $          -  up to $1,000 or by imprisonment for not less that 1 year or more than 5 years, or both, that the above
Total Airfare (attach passenger ticket copy)              $          -  statements are true and the described expenses, per diem and mileage were incurred in the discharge of
Total Airfare to AAA travel agency                                              official duties for the State and have not been reimbursed. I have not and will not file for reimbursement of
Total mileage @ 55 cents/mile                             $               -     these sums from any other source.
Total Miscellaneous expenses                              $               -     Traveler's Signature:                                                                Date:
Total Travel expenditure                                  $               -
Travel advance:                                                                 Signature of Authorized Budget Unit Approver (Cannot be a                            Date:
                                                                                subordinate of traveler):


Net reimbursement due:                                    $               -     Printed Name of Approver:                                                            Date:
                                                                                P.I. Approval (if applicable):                                                       Date:

				
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posted:10/1/2011
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