Travel Voucher TV2015

User Manual: TV2015

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TRAVEL VOUCHER

Form 13.20.10
Revised 11/2013
State of Mississippi:

Check One:
Employee
Contract Worker
Board Member

(Agency or Institution)

Name:

PIN/WIN #:

Address:

PID#:

I request reimbursement for subsistence and other authorized expenses paid by me incident to official travel for the State from
to
. The itemized statement follows.
(date)

Check
Box(es):

InState

(date)

Out-ofState

Out-ofCountry

PTE
Request

Prior to Trip Expenses (PTE) Request:

Per Diem in Lieu of Subsistence
Taxable Meals

Lodging

Non-Taxable Meals

Public Carrier

Lodging

Payment Information (Traveler complete, if known)

Travel in Private Vehicle

p#
Trip

Travel in Rented Vehicle

Travel Voucher #

Travel in Public Carrier

SAAS Ag #

Other:

SPAHRS Ag #
Fund #

Sub Total

Activity / Location

Less: Travel Advance

Org / Sub Org

Less: PTE Lodging

Rpt Category

Less: PTE Public Carrier

Project / Sub Proj

Net Payment (Overpayment)

Subject to any difference determined by verification, I certify that the above amount claimed by me for travel expenses for the period indicated is true and accurate in all respects, and that payment for any part has not been
received. In the event of overpayment, I agree that any future salary/travel disbursements may be debited to correct the overpayment

Traveler:

Title:

Date:

Approved by:

Title:

Date:

Verified by:

Title:

Date:

PENALTY FOR FRAUDULENT CLAIM - fine of not more than $250; civilly liable for full amount received illegally; removal from office or position held (Section 25-1-81 and 25-1-91, Miss. Code Ann.-1972)

Form 13.20.10

Itemized Statement of Travel Expense

Date

Purpose

SPAHRS Ag #

Points of Travel

SS #

Name:

Actual
Miles Breakfast

Actual
Lunch

Actual
Dinner

Daily
Meals
Allowed

Hotel

Item

Amount

Total
Mileage Reimbursement Rate
Total Mileage Dollar Amount

Enter 1 if overnight stay is required.
Enter 2 if overnight stay is NOT required.
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