travel payment document - iowa · document total less travel advancesless travel card paymentsless...

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