MILES RATE BREAKFAST ACTUALTOTAL
Y N
BUDGET FY
LINE
01
02
03
04
05
06
07
08
09
10
LUNCH DINNER
YEAR(CAL)
PERSONAL VEHICLEMEALS
Attach supporting documentation to the back of this form
TPSTATE OF IOWATRAVEL PAYMENTOFFICIAL
DOMICILE
PURPOSEOF
TRAVEL
OTHERSpecify:
NORMAL JOB DUTIES CONFERENCE/SEMINAR
LODGINGTRANSPORT
ANDOTHER
EXPENSESTRAVELTIME
NAME AND HOME ADDRESS ALTERNATE ADDRESS (Send warrant to) ACCOUNTING USE ONLY - REFERENCE ALL OTHER RELATED DOCUMENTS
MM/DD LEFT RETURNED FROM (RT = Round Trip) TO CHARGE ACTUALTOTAL
REIMBTOTAL
REIMBTOTAL
F - PHONEI - INTERNETL - LAUNDRY
DIRECT DEPOSIT?
CLAIMANT'S SIGNATURE DATE TRAVEL APPROVAL (SUPERVISOR'S SIGNATURE)
P - PARKINGR - REGISTRATIONS - SUPPLIES
TRAVEL DEPARTMENT AUTHORIZATION (TDA) NUMBER
Reimbursment RequestedDEPARTMENT CERTIFICATION
I CERTIFY THAT THE ABOVE EXPENSES WERE INCURRED AND THE AMOUNTS ARE CORRECT AND SHOULD BE PAID FROM THE FUNDS APPROPRIATED BY:
CODE OR CHAPTER SECTIONS:
TITLE DEPARTMENT TO BE CHARGED
OTHER:
EMPLOYEE VENDORCUSTOMER NUMBER
CHECK IF MEMBER OF BOARD OR COMMISSION
CLAIMANT'S CERTIFICATIONI CERTIFY THAT THE ITEMS FOR WHICH PAYMENT/REIMBURSEMENT IS CLAIMED WERE FURNISHED FOR STATE BUSINESS UNDER THE AUTHORITY OF THE LAW AND THAT THE CHARGES ARE REASONABLE, PROPER, AND CORRECT, AND NO PART OF THIS CLAIM HAS BEEN REIMBURSED OR PAID BY THE STATE, EXCEPT ADVANCES SHOWN, AND I UNDERSTAND THE ROUTINE USES OF THIS FORM.
COMMUTING MILES EXCLUDED?
Y NTRAVEL INCLUDES VICINITY MILES?
Y N
DOC TYPE DOCUMENT NUMBER DOC DATE ACCTG PRD VENDOR CUSTOMER NUMBER DOCUMENT TOTAL
TPEMPL VENDOR CUST NUMBER AMOUNTFUND DEPT UNIT SUB UNIT OBJT SUB OBJT
TP0119
TP AUDITED BY PAID DATE
DOCUMENT TOTAL
WARRANT NO.
DOC NUMBER DATE PAID
DOCUMENT TOTAL LESS Travel Advances LESS
Travel Card Payments LESS Agency Paid Expenses
ROUTINE USES OF THIS FORM ARE TO FULFILL IRS REQUIREMENTS, IDENTIFY INDIVIDUAL CLAIMS FOR PUBLIC INSPECTION, PROVIDE THE STATE VEHICLE DISPATCHER INFORMATION, AND TO PREPARE ANNUAL SALARY BOOK
TRANSPORTATION AND OTHER EXPENSESA - AIRB - BAGGAGEC - CAB/BUS
TOTALS
STATE VEHICLEPASSENGER
DOC NUMBER DATE PAID
DOCUMENT NUMBER
COST CENTER
T - TOLLS
U - POSTAGE/SHIPPING O - OTHER ---Specify--->
DATE