STATEMENT OF EXPENSE FOR REIMBURSEMENT FORM
A copy of the Approval for Travel Form signed by the Commissioner must accompany this form.

Required Fields in Bold

Name
 
Title
 
Address
 
 
City/State/Zip Code
 
Purpose of Trip
 
Other Staff Members on Trip
 
Dates
 
Site
 
Time & Date of Departure
 
Time & Date of Return
 
Roundtrip Transportation From
 
Roundtrip Transportation To
 
Mileage - $0.30 Per Mile by Automobile
 
Other (Describe) (Attach copy of airline ticket, etc. if applicable cost)
 
Rental Car Cost
 
Per Diem
 
Lodging: A copy of the hotel bill must be attached
 
Gratitude
 
Additional Expenses: Attach receipt(s) with explanation
 
TOTAL EXPENSES