TravelExpenseSample Travel Expense Sample
User Manual: TravelExpenseSample
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TRAVEL VOUCHER Form 13.20.10 Revised 05/2005 SAMPLE State Fire Academy State of Mississippi: (Agency or Institution) Social Security #: Name: PIN/WIN #: John Q. Public 123 Main St Address: Dates Go Here 000-00-0000 Check One: Employee Contract Worker Board Member PID#: Brandon MS 39042 I request reimbursement for subsistence and other authorized expenses paid by me incident to official travel for the State from January 1, 2009 Check Box(es): InState Out-ofState to January 4, 2009 Out-ofCountry PTE Request Prior to Trip Expenses (PTE) Request: . The itemized statement follows. Per Diem in Lieu of Subsistence Taxable Meals Lodging Non-Taxable Meals Public Carrier Lodging Payment Information (Traveler complete, if known) 0.00 300.00 Travel in Private Vehicle Trip # Travel in Rented Vehicle Travel Voucher # Travel in Public Carrier SAAS Ag # 0502 SPAHRS Ag # 502 Fund # 3502 Sub Total Activity / Location 5021 Less: Travel Advance 0.00 Other: Org / Sub Org Less: PTE Lodging Rpt Category Less: PTE Public Carrier Project / Sub Proj Net Payment (Overpayment) 300.00 300.00 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. Signature of Payee: ___________________________________________________________ Associate Signature (no pencil) Title: Associate Instructor Date: Verified by: _________________________________________________________________ MSFA Staff Member Signature Title: MSFA Staff Member Date: Approved for Payment: ________________________________________________________ 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) Itemized Statement of Travel Expense Date Purpose SPAHRS Ag #: 502 Points of Travel John Q. Public Miles 1/1/09 Teach Automobile Extrication-Clay County Brandon-West Point-Brandon 150 1/2/09 Teach Automobile Extrication-Clay County Brandon-West Point-Brandon 150 1/3/09 Teach Automobile Extrication-Clay County Brandon-West Point-Brandon 150 1/4/09 Teach Automobile Extrication-Clay County Brandon-West Point-Brandon 150 Actual Breakfast SS#: #REF! Actual Lunch Actual Dinner Daily Meals Allowed Other Authorized Expenses Hotel Item Amount Purpose: LIST CLASS NAME and LOCATION IN COLUMN Points of Travel: LIST STARTING POINT, DESTINATION, RETURN LOCATION (IF ALL IN SAME DAY) 600.00 Total Mileage Reimbursement Rate 0.00 0.00 0.00 0.00 0.00 0.50 Total Mileage Dollar Amount 300.00 Note: (1) Receipts for amounts paid for lodging and other expenses must accompany this voucher. (2) All activity pertaining to a certain date should be shown on the associated line or lines completely across the form. (3) Daily Meals Allowed equals the total of Actual Meals, not to exceed the Maximum Daily Meal Reimbursement. (4) If Tips are included in Other, then the type of tip must be identified. (5) A continuation sheet may be used if necessary. 0.00
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