DOMESTIC TRAVEL REIMBURSEMENT CLAIM FORMForm and all receipts must be submitted within 60 days of travel

Preparer's Name: Phone: Email: Dept.:

PAYEE

Name: Phone: Email: Dept.: City of Res.:

UCB Employee UCB Student Other

Emp/Stu/Ven ID: Affiliated Professor/Lab: US Citizen/Permanent Resident? Yes No

TRIP

Business Purpose (Attach backup, e.g. Agenda, etc.):

Special Circumstances/Personal Time (Date(s), time, location, etc.):

Destination(s):

Depart: Home Office Date: Time:

Return: Home Office Date: Time:

PRIVATE CAR (Mileage)

License Plate #: Liability Insurance: Yes No

Date Drove From Drove To Rate

City Registered In:

# of Miles Amount00.56 $00.56 $00.56 $00.56 $00.56 $00.56 $00.56 $

AIR

Airfare:

Charged to Connexxus don't add to total, attach itinerary Paid personally, enter amount Paid other, enter amountAmount

OTHER TRANSPORT/RENTAL CAR (Shuttle, taxi, bart, rail, rental car, other):

Ground Trans. Date From To AmountShuttle $

Shuttle $

Taxi $

Taxi $

Bart $

Bart $

Bart $

Rental CarIntermediate

Explain: Attach receipts for all rental car expenses

Rental Car InsuranceInsurance is generally not reimbursed

Amount$

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Instructions for this form can be found on the CSS website

There is limited space available on this form, but please do your best to print clearly in the boxes provided.

Economy/Compact

Other (Explain)

a.m.

a.m.

p.m.

p.m.

Total Other Transport:

Total Air:

Total Private Car:

OTHER EXPENSE

$

$

$

$

$

$

$

$

Date Description Amount

$

$

$

$

$

Conference/Registration Fee: Attach agenda Charged on BluCard Don't add to total Paid personally Enter amount $

Meals & Incidentals (M&IE -Includes tips for porters, hotel maids, etc.)

DAILY EXPENSES

Location Room & Tax Breakfast Lunch Dinner Incidentals Total M&IE Total Daily

Reductions:1. Travel Advance? Attach original request Amount 2. Other Reductions?

ESTIMATED TOTAL REIMBURSEMENT NOT TO EXCEED:COA

ACCOUNT(OPT) FUND DEPT. ID PROGRAM CF1 CF2 AMOUNTOPTIONAL:Accounting Approval(Department specific)

CERTIFICATION

Expense Expense ExpenseExpense AmountAmountAmountAmount

I certify that the above is a true statement, that the expenses claimed were incurred by me on official University business on the date shown, and that I have attached original receipts for each expense of $75 or more, as required by University policy.

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There is limited space available on this form, but please do your best to print clearly in the boxes provided.

Date

Lodging

Total Lodging: Total M&IE:

Total Daily Expenses:

ESTIMATED TOTAL TRAVEL EXPENSES:

Total Other Expenses:

Enter reduction amount with a negative sign.

Exceptional Signature: Name: Title: Date:

Traveler's Signature: Name: Title: Date:

Authorizer's Signature: Name: Title: Date:

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Preparers Name: Instructions for this form can be found on the CSS website: Email: Dept: Name: Phone: Email_2: Dept_2: City of Res: EmpStuVen ID: Affiliated ProfessorLab: Business Purpose Attach backup eg Agenda etc: Special CircumstancesPersonal Time Dates time location etc: Destinations: Date: Date_2: License Plate: Time: Time_2: City Registered In: Amount_2: Attach receipts for all rental car expenses: Amount_4: Expense: Amount_5: Expense_2: Amount_6: Expense_3: Amount_7: Expense_4: Amount_8: undefined_41: fill_66: undefined_42: fill_67: undefined_43: fill_68: undefined_44: fill_69: Date_5: undefined_45: undefined_46: undefined_47: undefined_48: Description 1: Description 2: Description 3: Description 4: Description 5: Amount_9: fill_71: fill_72: fill_73: fill_74_2: ESTIMATED TOTAL EXPENSES: ACCOUNTOPT: FUND: DEPT ID: PROGRAM: CF1: CF2: AMOUNT: Department specific: undefined_65: undefined_66: undefined_67: undefined_68: undefined_69: undefined_70: fill_135: undefined_71: undefined_72: undefined_73: undefined_74: undefined_75: undefined_76: undefined_77: fill_136: undefined_78: Payee Status:

Citizen Resident:

Depart:

Return:

Time1:

Time2:

LiabilityInsurance:

Airfare Connexxus: Paid Personally: Paid Other: Rental Car:

Rental Car Insurance: Charged BluCard: PaidPersonally: Reductions: Date_3: 0: 1: 2: 3: 4: 5: 6:

Drove From: 0: 1: 2: 3: 4: 5: 6:

Drove To: 0: 1: 2: 3: 4: 5: 6:

Rate: 0: 0.5751: 0.5752: 0.5753: 0.5754: 0.5755: 0.5756: 0.575

of Miles: 0: 1: 2: 3: 4: 5: 6:

Amount Calc: 0: 01: 02: 03: 04: 05: 06: 0

Grd Trans: 0: -1: -2: -3: -4: -5: -6: -

Date_4: 0: 1: 2: 3: 4: 5: 6:

From: 0: 1: 2: 3: 4: 5: 6:

To: 0: 1: 2: 3: 4: 5: 6:

Amount_3: 0: 1: 2: 3: 4: 5: 6:

Date_6: 0: 1: 2: 3: 4: 5: 6: 7: 8:

Location: 0: 1: 2: 3: 4: 5: 6: 7: 8:

Room Tax: 0: 1: 2: 3: 4: 5: 6: 7: 8:

Breakfast: 0: 1: 2: 3: 4: 5: 6: 7: 8:

Lunch: 0: 1: 2: 3: 4: 5: 6: 7: 8:

Dinner: 0: 1: 2: 3: 4: 5: 6: 7: 8:

Incidentals: 0: 1: 2: 3: 4: 5: 6: 7: 8:

M IE Amount: 0: 01: 02: 03: 04: 05: 06: 07: 08: 0

Name_2: 0: 1: 2:

Title: 0: 1: 2:

Date_7: 0: 1: 2:

Signature Traveler: Signature Authorizer: Signature Exceptional: Total Mileage: 0Total Other Transport: 0Total Other Expense: 0Total Daily: 0: 01: 02: 03: 04: 05: 06: 07: 08: 0

Total RoomTax: 0Total M&IE: 0Total Daily Expenses: 0Total Expenses: 0Other Reductions: Reimbursement Not: 0Total Airfare: 0OtherPaidPersonally: