Travel Voucher TV2015
User Manual: TV2015
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Form 13.20.10 TRAVEL VOUCHER
Revised 11/2013 State of Mississippi: Employee
N
ame: PIN/WIN #: Contract Worker
Board Member
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.
Check In- Out-of- Out-of- PTE
Box(es): State State Countr
y
Reques
t
(date) (date)
Check One:
(Agency or Institution)
Payment Information (Traveler complete, if known)
Trip #
Travel in Private Vehicle
Travel in Rented Vehicle
Taxable Meals
Non-Taxable Meals
Lodging
Per Diem in Lieu of Subsistence
Lodging
Public Carrier
Prior to Trip Expenses (PTE) Request:
Other:
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:
Org / Sub Org
Rpt Category
Fund #
Activity / Location
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)
Project / Sub Proj
SAAS Ag #
SPAHRS Ag #
p
Travel Voucher #
Less: PTE Lodging
Less: PTE Public Carrier
Net Payment (Overpayment)
Sub Total
Less: Travel Advance
Travel in Public Carrier
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 SPAHRS Ag # Name: SS #
Daily
Actual Actual Actual Meals
Date Purpose Miles Breakfast Lunch Dinner Allowed Hotel Item AmountPoints of Travel
Total
Enter 1 if overnight stay is required.
Enter 2 if overnight stay is NOT required.
Mileage Reimbursement Rate
Total Mileage Dollar Amount
