Spreadsheet: 0354d6ef-3aba-4974-9799-9f07f87b6aa6
Sheet: Sheet1

FY12 UNIVERSITY OF ILLINOIS TRAVEL / EXPENSE REIMBURSEMENT FORM (use for expenses incurred after 4/16/12) | 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 | Unnamed: 15
Name: |  |  |  | Dept. Name & M/C: |  |  |  | Dept. Contact: |  |  |  |  | UPAY Use Only
Banner Vendor Number: |  |  |  | Employee |  | Choose the appropriate status from the selections to the left |  | Phone: |  |  |  |  | Banner Document #
Address: |  |  |  | Student/Employee |  |  |  | Transportation purchased with P-Card: |  |  |  |  | Address Sequence:
 |  |  |  | Student |  |  |  | Amount: |  |  |  |  | Address Code:
 |  |  |  | Is lodging conference hotel? |  |  |  | P-Card Transaction # : |  |  |  |  | Check Print Location:
 |  |  |  | Headquarters |  |  |  | Advance Amount: |  |  |  |  | Form Revised 4/16/12
 |  |  | # of | Auto | Transportation
 | Departed From/ |  | Auto | [NAME] |  |  | Taxi, Parking |  |  |  | Meals or |  | [NAME]. |  | Daily
Date | Arrived At | Time | Miles @ | ment | Air, Rail, Etc. | Car Rental | Tolls, Etc. |  | Lodging |  | Per Diem |  | Expense |  | Totals
 |  |  | 0.555 | Auto Calculate | Amount in U.S. $ | Amount in U.S. $ | Amount in U.S. $ |  | Amount in U.S. $ |  | Amount in U.S. $ |  | Amount in U.S. $ |  | Auto Calculate
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 |  |  |  | 0 |  |  |  |  |  |  |  |  | Desc: |  | 0
 | Total Travel Expense: |  |  | 0 | 0 | 0 | 0 |  | 0 |  | 0 |  | 0 |  | 0
Destination and Purpose of Trip: |  |  |  |  |  |  |  |  | Total Miscellaneous Expenses |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  | TOTAL TRAVEL & MISC. EXPENSE |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  | Less Travel Advance |  |  | Doc. # |  |  | 0
Employee Miscellaneous Expense Reimbursement |  |  |  |  |  |  |  |  | Total Due To/(Owed by) Employee |  |  |  |  |  | 0
 |  |  |  |  |  |  | FOAPAL ( * = [NAME]; For Travel Advance, complete Chart code on last line)
Date | Description |  |  |  |  | Amount | Chart* | Index | Fund* | Orgn* | Acct* | Program* | Activity | Location | Amount
 |  |  |  |  |  |  | FOP TITLE:
 |  |  |  |  |  |  | FOP TITLE:
 |  |  |  |  |  |  | FOP TITLE:
 |  |  |  |  |  |  | FOP TITLE: |  | Travel Advance (*Complete Chart Code below)
 | TOTAL |  |  |  |  | 0 |  |  | 200450 |  | 53080 |  |  |  | 0
 |  |  |  |  |  |  |  | Instructions:
 |  |  |  |  |  |  |  | 1. Attach original paid receipts for all hotels, registrations, and miscellaneous items.
CERTIFICATION:  I cerify that I have not, or will not, receive remuneration from any source for the expenses claimed.  I have not claimed meal per diem for any meals(s) |  |  |  |  |  |  |  | 2. Attach customer copy of all air, rail, or bus tickets.
that were provided to me at no additional cost.  If a business meal(s) was paid for via P-Card during this trip, that meal(s) was deducted from the per diem claimed. |  |  |  |  |  |  |  | 3. See OBFS Web site for detailed instructions.
TRAVEL CERTIFICATION:  I certify that, in accordance with Section 12 of "An Act in Relation to State Finance", the above amount is correct and just; that the detailed items charged for subsistence were actually paid; that the expenses were occasioned by
official business or unavoidable delays requiring the stay at hotels for the time specified; that the journey was performed with all practicable dispatch by the shortest route usually traveled in the customary reasonable manner; and that I have not been
furnished with transportation or money in lieu thereof for any part of the journey therein charged for.   If I have used my private vehicle, or private aircraft, I also certify that I was duly licensed and carried at least the minimum insurance coverage required by
statutes and University Travel Regulations.  "I certify that the purpose of this travel was initially approved by the appropriate authority."
Note: Reimbursements must be claimed within 60 days of completion of travel or a purchase; otherwise, the reimbursement is considered taxable income.
Employee Signature: |  |  |  |  |  |  |  | Date: |  |  | University of Illinois
We, the Undersigned, Hereby Certify that the Above Bill is Correct and Payable from the Appropriation Shown. |  |  |  |  |  |  |  |  |  |  | Urbana/Champaign, Chicago, Springfield
Approved ([NAME], Director, Dept. Head): |  |  |  |  |  |  |  | Date: |  |  | OBFS Approval:
Yes
No
UNIVERSITY CAR
PERSONAL CAR
RODE WITH SOMEONE ELSE
COMMERCIAL PLANE
RAIL
RENTAL CAR
Urbana/Champaign
Chicago
Springfield