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 |  | TRAVEL AND EXPENSE FORM
 | Financial & Administrative Services |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Required:  Please Complete this Section |  |  |  |  |  |  |  | Important Note
 | Employee Name: |  |  |  |  | Ext: |  |  |  | Form of Payment (select from menu): |  |  | Mail to Department Listed |  |  |  |  | Dates: |  |  | to |  |  |  |  | If expenses were incurred for multiple trips or partial expenses were incurred outside of Canada, please use separate expense reports for each to allow the tax rebates to be calculated correctly.
 | Address: |  |  |  |  |  |  |  |  | Name: |  |  |  |  | ext |  |  |  | dd/mm/yy |  |  | dd/mm/yy
 | Postal Code: |  |  | Dept: |  |  |  |  |  |  |  |  |  |  |  |  |  | For Travel/Expenses Outside Canada: |  |  |  |  |  |  |  | Employee Expense Reimbursement Forms must be filled out electronically
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Check here: |  |  |  | [ |  | ] | (no HST rebate)
 | Purpose or Rationale for Travel and/or Expenses: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | *AND complete a separate report
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | For Travel/Expenses Within Canada |  |  |  |  |  |  | (only federal HST rebate) | Cheque Payable In (select form menu):
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Check here if all/some in other prov. |  |  |  | [ |  | ]
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | *AND enter GST in Column L |  |  |  |  |  |  |  | Note: Only one currency per report
 | NOTE:  Report should be submitted to Accounts Payable with original receipts attached in order listed below.
 | Date              (dd/mm/yy) | Vendor & Description of Expense |  |  |  | # km traveled |  | Km $ (auto-calculated) | Accomm. $ |  | Actual Meals $ |  |  | Transportation Costs $ | Other $ |  |  | Totals incl. taxes $ (auto-calculated) | Account #                                    xxx-xxx-xxx |  |  | Research Code, if applicable |  |  |  | Federal Portion of HST $ -- Only if expense was in another prov. | HST $ -- Only if expense in [NAME].                               (auto-calculated)
 | A | B |  |  |  | C |  | D=Cx$0.50 | E |  | F |  |  | G | H |  |  | I=D+E+F+G+H | J |  |  | K |  |  |  | L | M
 | Column Totals (auto-calculated):
 | Prepared by: |  |  |  |  | Ext. |  |  |  |  |  |  |  | Grand Total (HST incl) |  |  |  |  |  | For Finance Use Only:
 |  |  |  |  |  |  |  |  |  |  |  |  | Less: Advance(s) |  |  |  |  |  |  | [ | ]  CR 111-006-018  $_________
 | PAYEE/RESEARCHER |  |  |  |  |  |  |  |  |  |  |  | Please put OC/UC # in box at right |  |  |  |  |  |  | [ | ]  CR 111-006-028  $_________
 | CERTIFICATION: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Net Payment Due to Payee
 | I hereby certify that the expenses listed on this form were incurred on university business and have not and will not be reimbursed, in whole or in part, by any other source.   I hereby certify that the above listed expenses are in accordance with University policies and procedures. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Returned to Brock** |  | ** Attach cheque payable to Brock University or pay cash to cashier in Finance department and attach receipt as proof of repayment.
 | [NAME] (IF APPLICABLE): |  |  |  |  |  |  |  |  |  |  | AUTHORIZED [NAME]
 | I hereby certify that any amounts on this form that are for research are for the purposes for which the grant  was awarded, have been made in accordance with granting agency requirements, and have not and will not be reimbursed, in whole or in part, by any other source. |  |  |  |  |  |  |  |  |  |  | I hereby certify that I have reviewed the above expenses and information attached and that to the best of my knowledge they are true, correct, and complete.  I hereby certify that the above listed expenses are in accordance with University policies and procedures.
 | Print Name: |  |  |  |  | Title: |  |  |  |  |  |  | Print Name: |  |  |  |  |  |  | Title:
 | Signature: |  |  |  |  | Date: |  |  |  |  |  |  | Signature: |  |  |  |  |  |  | Date:
 |  |  |  |  |  |  | dd/mm/yy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | dd/mm/yy
 | AUTHORIZED APPROVER >$5,000 (IF APPLICABLE) |  |  |  |  |  |  |  |  |  |  | AUTHORIZED APPROVER >$15,000 (IF APPLICABLE)
 | I hereby certify that I have reviewed the above expenses and information attached and that to the best of my knowledge they are true, correct, and complete.  I hereby certify that the above listed expenses are in accordance with University policies and procedures. |  |  |  |  |  |  |  |  |  |  | I hereby certify that I have reviewed the above expenses greater than $15,000 and information attached and that to the best of my knowledge they are true, correct, and complete.  I hereby certify that the above listed expenses are in accordance with University policies and procedures.
 | Print Name: |  |  |  |  | Title: |  |  |  |  |  |  | Print Name: |  |  |  |  |  |  | Title:
 | Signature: |  |  |  |  | Date: |  |  |  |  |  |  | Signature: |  |  |  |  |  |  | Date:
 |  |  |  |  |  |  | dd/mm/yy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | dd/mm/yy
 | For Research Accounts Only (33x-xxx-xxx):  E1 = Equipment >$5000; E2 = Equipment <$5000; M1 = Materials, supplies and other expenditures; M2 =  [NAME]; M3 - Professional and technical services/contracts; S9 = Salaries - Other; T1 = Travel; OH = Overhead
 | Finance Use Only |  | Verified cash receipt attached for funds returned: |  |  |  |  |  |  |  |  |  |  |  |  | Verified by: |  |  |  |  |  |  |  |  | Date:
 | version January 2014
 | E1
 | E2
 | M1
 | M2
 | M3
 | S9
 | T1
 | OH
 | Canadian
 | US
 | Mail to Department Listed
 | Mail to Address Shown