Spreadsheet: 1791cd6f-0a1e-4adf-91c2-667100651944
Sheet: Travel Reimbursement

 |  |  |  |  | The University of North Carolina - General Administration
 |  |  |  |  | REQUEST FOR REIMBURSEMENT OF TRAVEL AND OTHER EXPENSES
 |  |  |  |  | INCURRED IN THE DISCHARGE OF OFFICIAL DUTY - INCLUDING PER DIEM (Rev 01/01/2013)
INSTRUCTIONS:  Prepare in duplicate.  Attach all necessary receipts or other supporting documents to this form and submit the original
to the Services Office within 30 days after travel status terminates.  Retain one (1) copy for your files.
PAYEE'S NAME |  |  | TITLE |  |  |  |  | DATE
DEPARTMENT/DIVISION |  |  |  |  | Travel Auth. #/Date |  |  | Duty Station (City)
DEPARTMENT/DIVISION ADDRESS |  |  |  |  | ACCOUNT NUMBER
FROM | Period Covered by this Voucher |  |  | THROUGH | Mailing Address (if not reimbursed via EFT):
PURPOSE OF TRIP
 |  |  |  |  |  |  |  | AMOUNT | OFFICE USE ONLY
 |  |  |  |  | Total Expenses
Under penalties of perjury I certify this is a true and accurate statement of the city of lodging, expenses |  |  |  |  | Total Advance
and allowances incurred in the service of the state.  Unless I have marked out this sentence, I |  |  |  |  | Amount Due-UNC GA
voluntarily give permission to UNC GA to electronically deposit my travel reimbursement to the |  |  |  |  | Amount Due-Applicant
bank account I use for Payroll direct deposit or another designated bank account. |  |  |  |  | I have examined this reimbursement request and certify that it is just and reasonable.
 | Claimant |  |  |  |  |  | Department/Division Head
 | TRAVEL (SHOW EACH CITY VISITED) MUST INCLUDE DEPARTURE AND ARRIVAL TIMES IF MEAL ALLOWANCE IS REQUESTED |  | TRANSPORTATION - MILEAGE, AIRFARE, RENTAL CAR, TRAIN, PARKING, TAXI, TOLL |  |  | SUBSISTENCE - MEALS & HOTEL |  |  | OTHER EXPENSES      - REGISTRATION FEE, OTHER (BAGGAGE TIP, INTERNET, FAX, COPIES, PHONE)
DAY | FROM | TO | (1) MODE | DAILY PRIVATE CAR MILEAGE | TRANSPORT COSTS TO BE REIMBURSED | (2) TYPE | AMOUNT | (3)   DAILY TOTALS | EXPLANATION | (4)   AMOUNT
 |  |  | C@.30 |  |  |  |  |  | Registration Fee
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
(1) TRAVEL MODE |  | (2) SUBSISTENCE | In-State | Out-of-State | SUBTOTAL |  |  | SUBTOTAL |  | SUBTOTAL
C=CAR |  | BREAKFAST | 8 |  | TRANS. |  |  | SUBSIST. |  | OTHER EXP.
AIRFARE (Includes excess bagage) |  | LUNCH | 10.45
RENTAL CAR |  | DINNER | 17.9 | 20.3
TRAIN |  | HOTEL | 63.9 | 75.6
PARKING, TAXI, TOLL |  | (3) 24-hour period
REIMBURSEMENT SUMMARY
 | Amount | Transportation |  | Amount | Subsistence |  |  | Amount | Other
31_____1 |  | Air | 31___4 |  | Lodging |  | 31_____6 |  | Other
31_____2 |  | Ground | 31___5 |  | Meals |  | 31_____9 |  | Registration Fee
31_____3 | 0 | Other |  |  |  |  | 319_____ |  | Advance
 |  | Total Transportation |  |  | Total Subsistance |  |  |  | Total Other
INVOICE ________________________________________________ |  |  |  |  |  | REIMBURSEMENT GRAND TOTAL
 |  |  |  |  | (continued from previous page)
 | TRAVEL (SHOW EACH CITY VISITED) MUST INCLUDE DEPARTURE AND ARRIVAL TIMES IF MEAL ALLOWANCE IS REQUESTED |  | TRANSPORTATION - MILEAGE, AIRFARE, RENTAL CAR, TRAIN, PARKING, TAXI, TOLL |  |  | SUBSISTENCE - MEALS & HOTEL |  |  | OTHER EXPENSES      - REGISTRATION FEE, OTHER (BAGGAGE TIP, INTERNET, FAX, COPIES, PHONE)
DAY | FROM | TO | (1) MODE | DAILY PRIVATE CAR MILEAGE | TRANSPORT COSTS TO BE REIMBURSED | (2) TYPE | AMOUNT | (3)   DAILY TOTALS | EXPLANATION | (4)            AMOUNT
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
 |  |  | C@.30
 |  |  | C@.56.5 |  |  | Breakfast
 |  |  | Airfare |  |  | Lunch |  |  | Other
 |  |  | Rental |  |  | Dinner
 |  |  | Train
 |  |  | Parking, Taxi, Toll |  |  | Hotel
(1) TRAVEL MODE |  | (2) SUBSISTENCE | In-State | Out-of-State | SUBTOTAL |  |  | SUBTOTAL |  | SUBTOTAL
C=CAR |  | BREAKFAST |  |  | TRANS. |  |  | SUBSIST. |  | OTHER EXP.
AIRFARE (Includes excess bagage) |  | LUNCH
RENTAL CAR |  | DINNER
TRAIN |  | HOTEL
PARKING, TAXI, TOLL |  | (3) 24-hour period