Spreadsheet: c5707479-d5ff-4f6b-ac11-3ff99578e46b
Sheet: Sheet1

STATE OF COLORADO | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14
TRAVEL EXPENSE
DEPARTMENT |  |  |  | DIVISION OR AGENCY |  |  |  |  |  | MONTH |  | YEAR
 | TRAVEL |  |  |  | MILEAGE |  |  | MEALS AND LODGING
Date |  |  | Time | Time | No. | Rate |  |  |  |  |  | 5 |  | Total
 | FROM | TO | [NAME] | Return | [NAME] | Per | Total | Bkst. | Lunch | Dinner | Lodg. | Inci- | Total | Reimbursable
 |  |  |  |  |  | Mile |  |  |  |  |  | dental |  | Items
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
 |  |  |  |  |  | 0.51 | 0 |  |  |  |  |  | 0 | 0
TOTALS |  |  |  |  |  |  | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0
MISCELLANEOUS EXPENSE:
(See page two for additional space)
PURPOSE OF TRIP: |  |  |  |  |  |  |  | LESS TRAVEL ADVANCE
 |  |  |  |  |  |  |  |  |  | TOTAL |  |  |  | 0
PERSONS AND AGENCIES CONTACTED:
"I certify that the statements in the above schedule are true and just in all respects; that payment of the amounts claimed herein has not and will not
be reimbursed to me from any other sources; that travel performed for which advance/reimbursement is claimed was or will be performed by me
while on State business and that no claims are included for expenses of a personal or political nature or for any other expenses not authorized by
the Fiscal Rules; and that I actually incurred or paid the operating expenses of the motor vehicle for which reimbursement is claimed on a mileage
basis. Further, I hereby authorize the State to deduct from my pay any amount paid to me in excess of my actual incurred expenses.  The signatures
on this form constitute approval for use of private auto within the Metro area or a 65-mile radius of the office and that the conditions of the use of
private auto have been met and adhered to."
PAYEE SIGNATURE |  |  |  |  |  |  | DATE |  |  |  | EMPL #
PAYEE PRINT NAME AND PHONE NUMBER |  |  |  |  |  |  | MAIL ADDRESS
Reimbursement will by paid State warrant if not checked. |  |  |  |  |  | PLEASE PAY BY ELECTRONIC FUNDS TRANSFER
RECOMMENDED FOR APPROVAL
FISCAL OFFICER |  |  | SUPERVISOR SIGNATURE & PHONE NUMBER |  |  |  |  |  | APPROVING AUTHORITY
ACRONYM | FUND | AGENCY  ID | ORG | APPR | PROGRAM |  | OBJ | SUB | B/S | GBL | RPTG CAT |  | PROJECT | AMOUNT
Shaded areas in coding string to be completed by the District Accounting Office |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL | 0
TRVLEFT.XLS (Revised 2/2012)
INSTRUCTIONS FOR ELECTRONIC FUND TRANSFER
OF TRAVEL EXPENSE REIMBURSEMENT
 | If an employee would like reimbursement deposited directly to the employee's bank
 | account and the employee has been pre-noted on COFRS, please check the box
 | "Please Pay by Electronic Fund Transfer".
 | If an employee would like to change or add reimbursement deposited directly to
 | the employee's bank account, please contact your District Accounting Office to
 | obtain "Employee's Authorization for Electronic Funds Transfer Form".  The box for
 | "COFRS" - Employee Reimbursement (Travel, etc.) must be checked.  This
 | form and the employee's voided check of deposit slip will be forwarded by the
 | District Accounting Office to the State Controller's Office (SCO) and will
 | be the basis for electronically verifying the "path" to the employee's account.
 | If no bank reject is received in three (3) weeks, future COFRS payments may be
 | paid by EFT if the employee checks the box "Please Pay by Electronic Fund
 | Transfer".
 |  |  |  |  | ADDITIONAL SPACE FOR MISCELLANEOUS EXPENSES, EXPLANATIONS AND COMMENTS:
 |  |  |  |  |  | PLEASE SUBMIT THIS PAGE WITH THE TRAVEL EXPENSE REIMBURSEMENT FORM