International Travel Reimbursements Form

INTERNATIONAL TRAVEL REIMBURSEMENT claim FORM
Form and receipts must be submitted within 45 days of expenditure
Date:
Preparer:
Dept.:
If we have questions, who should we contact? Payee:
PAYEE
Preferred Contact Info. (if not Payee): Name:
UC Employee:
Email:
Phone:
Student:
Vendor:
Other:
Phone:
Email:
Name:
US Citizen/Permanent Resident? Yes
Preparer:
Emp/Stu/Vend.ID:
Other:
Org.Node:
Address:
If no, you will be contacted by CSS for more info. e.g. Passport, I-94,UC-W8-BEN,COAA
No
TRIP
Business Purpose: State date(s), location(s) and reason(s):
Details for any Personal Time, Entertainment or Special Circumstances: Enter date(s), location(s). For entertainment, also include business
purpose, guest names & their affiliation. Enter meal costs in M&IE section blw.
TRANSPORTATION & MISC. EXPENSES
Air Fare: Seeking Reimbursment? No
Yes
(If Direct Bill attatch Connexxus Itinerary)
Direct Bill? Yes
Attatch Itinerary & Proof of Payment
Airfare Amount:
Personal Car: Standard Mileage Rate is 54.0 cents for travel on or after January 1, 2016
Drove To Address
Drove From Address
Date
Rate
Miles
Amount
0.00
0.00
0.00
0.00
Rental Car: Economy/Compact/Intermediate
Reason for "Other Size" Car:
Transportation & Other Misc. Expenses:
Taxi
Gas
Parking
BART/Rail
Toll
Taxi
Total Mileage Amount:
Other Size
Car Rental Amount:
Shuttle
Baggage
Shuttle
Other
Conference/Registration Fee: Seeking Reimbursment? No
Paid on Blue Card?* No
Optional Notes/Comments:
$0.00
0.00
Yes
Yes
Other
Tips
Tips
Phone
Internet
(non meal)
Other
Conference/Registration Fee Amount:
*(If paid on bluCard, do not enter amount)
$0.00
LODGING, M&IE EXPENSES
TOTAL TRANSPORTATION & MISC. EXPENSES:
Lodging, Meals & Incidental (M&IE): Travelers should only claim Actual Expenses up to Federal Per Diem Rate for the locality of travel.
If additional space is needed, either attach another "daily expense" section or your own detailed spreadsheet of expenses.
Dates
Currency
Location
Lodging
Breakfast
T
Optional Notes:
Travel Advance Amt: Enter (-) amt:
Travel Advance? Yes
Fund
CERTIFICATION
COA
Account
Dept
Program
Dinner
Light Ref
M&IE TOTAL:
LODGING & M&IE TOTAL:
$0.00
LODGING TOTAL:
Lunch
ESTIMATED REIMBURSMENT:
CF 1
CF 2
$ Amount
M&IE Totals
0.00
0.00
0.00
0.00
0.00
0.00
$0.00
$0.00
$ 0.00
Optional: Chartstring Description
Accounting Approval (Dept Specific)
I certify that the above is a true statement, that the expenses claimed were incurred by me on official University business
on the dates shown, and that I have attached original receipts for each expense as required by University policy.
Traveler Name andTitle:
Traveler Signature:
Authorizing Name and Title:
Authorizing Signature:
Date:
Date:
02/02/2016