Travel Voucher 2015x Voucher2015

User Manual: TravelVoucher2015

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TRAVEL VOUCHER

Form 13.20.10
Revised 1/2015
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

Per Diem in Lieu of Subsistence
Taxable Meals

Prior to Trip Expenses (PTE) Request:
Lodging

Non-Taxable Meals

Public Carrier

Lodging
Travel in Private Vehicle

Payment Information (Traveler complete, if known)
Trip #

Travel in Rented Vehicle

Travel Voucher #

Travel in Public Carrier

SAAS Ag #

502

SPAHRS Ag #

502

Other:

Fund #

3502

Sub Total

Activity / Location

5021

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: Adjunct Instructor

Date:

Approved by:

Title: Staff Instructor

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

Actual
Miles Breakfast

Please list the County in which the course was
delivered
COURSE COUNTY:
__________________________________

Total
Mileage Reimbursement Rate
Total Mileage Dollar Amount

SS #

Name:

Actual
Lunch

Actual
Dinner

Daily
Meals
Allowed

Hotel

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Item

Amount

N/A

0.575
2

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