Spreadsheet: 0235b95f-f310-429a-8cf1-c380a82d5e32
Sheet: AP Travel Form 1

 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 1
NORTHERN ARIZONA UNIVERSITY |  |  |  |  |  |  | Exhibit J |  | TA # |  |  |  | Expense Report #
TRAVEL EXPENSE SUMMARY |  |  |  |  |  |  | Revised 06/25/2012 |  | Cash Advance #
Prepared by: |  |  |  | Date: |  |  | Traveler: |  |  |  |  | Emplid #: |  |  |  | State [NAME]
Entered By: |  |  |  | Date: |  |  | Department: |  |  |  |  | Phone: |  |  |  | Rental Vehicle
Purpose of Travel/Description: |  |  |  |  |  |  | Destination: |  |  |  |  | County: |  |  |  | Personal Vehicle
Traveler's Home Address: |  |  |  |  |  |  | Traveler Duty Post: |  | Comments: |  |  |  |  |  |  | Dr.[NAME] #
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Pay Codes:    C - NAU Purchasing Card
TRAVEL EXPENSE SUMMARY |  |  |  |  |  |  |  |  |  |  |  |  |  |  | R-Requisition |  | T-Third Party
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Pay Code |  | Pay Code |  | Pay Code
 |  |  |  |  |  |  |  |  |  |  |  |  | Pers. Vehicle |  |  |  | Gas/
 |  |  |  |  |  |  |  |  |  | M & IE |  |  | See Back |  | Lodging |  | Other |  | Transp.
Date |  | Address Departed From |  |  |  | Time | Address Arrived At |  | Time | B | L | D | Miles X .445
 |  |  |  |  |  |  |  |  | TOTALS: $
TRAVELER CERTIFICATION |  |  |  |  |  |  |  |  |  | Meal Total |  |  |  |  | Trip Total
I certify that the items of expense in this claim were incurred for authorized official state
business and that they are correct and proper charges.  If this travel claim involves travel by |  |  |  |  |  |  |  | Third Party: |  |  |  |  |  |  | T - Less Paid via Third Party
vehicle, I certify that I am an Authorized Driver, have a valid Arizona's driver's license, and if a |  |  |  |  |  |  |  |  | *Include additional disclosure details on pg. 2*
personal vehicle was used, I certify that the vehicle has liability insurance coverage.  I further |  |  |  |  |  |  |  |  |  |  |  |  |  |  | NAU Total
certify any third party payments or reimbursements are disclosed on this form.  IF I AM |  |  |  |  |  |  |  | Advances: |  |  |  |  |  |  | Less Paid Advances
OVERPAID or fail to settle my account in full, I authorize NAU to deduct the balance against my |  |  |  |  |  |  |  | Requisition: |  |  |  |  |  |  | R - Less Paid via Req
wages (ARS 35-195.02B).  I UNDERSTAND THAT FILING A FALSE CLAIM IS A FELONY. |  |  |  |  |  |  |  | NAU P-Card: |  |  |  |  |  |  | C - Less Paid via Purch Card
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Due to/(from) traveler
 |  |  |  |  |  |  |  |  |  | Exceptions to Policy
 |  |  |  |  |  |  |  |  |  | Lodging:
Traveler Signature: |  |  |  |  |  |  |  | Date: |  | Transportation:
 |  |  |  |  |  |  |  |  |  | Cash Advance:
 |  |  |  |  |  |  |  |  |  | Multiple Rep (pg. 2)
 |  |  |  |  |  |  |  |  |  | Other (specify)
 |  |  |  |  |  |  |  |  |  | *continue any additional details on page 2*
SUPERVISOR CERTIFICATION
I certify that this trip was authorized by me in writing via email and that the trip was necessary and appropriate for this employee's
job duties in his/her conduct of official Arizona state business.  I further certify that, to the best of my knowledge, the items of expense |  |  |  |  |  |  |  |  |  | Exception to Policy Signature: |  |  |  |  |  |  |  | Date:
in this claim are correct and proper charges. |  |  |  |  |  |  |  |  |  | I certify that all exceptions to the travel policy are appropriate, reasonable, and appear to be for a
 |  |  |  |  |  |  |  |  |  | valid university purpose and that all supporting documentation is attached with this claim.
 |  |  |  |  |  |  |  |  |  |  |  |  | M & IE   Rates
 |  |  |  |  |  |  |  |  |  | Leave  < 6am |  |  | B       $  7.00     $  8.00     $  9.00      $10.00     $11.00     $12.00
 |  |  |  |  |  |  |  |  |  | Leave  < 11am  Return > 2pm |  |  | L       $ 10.00     $11.00     $13.00     $14.00     $16.00     $17.00
 |  |  |  |  |  |  |  |  |  | Return > 8pm or overnight |  |  | D       $17.00     $20.00     $22.00     $25.00     $27.00     $30.00
Supervisor Signature: |  |  |  |  |  |  |  | Date: |  |  |  |  | $34.00     $39.00     $44.00     $49.00     $54.00     $59.00