Travel Reimbursement
Is this a quote that you will be sending to your supervisor?
Yes
No
Personal Info
Name:
Department:
Email Address:
Required if you would like to email a copy. Separate multiple addresses with a comma.
Travel Criteria
Description of Travel:
Destination City, State:
Travel Started:
Date & Time:
When you left home
Travel Ended:
Date & Time:
When you returned home
Normal Start Time:
Time:
When you normally report to work
Normal End Time:
Time:
When you normally leave work
Transportation
Did you take a county vehicle?
Yes
No
Was a county vehicle available?
Yes
No
Round Trip Personal Vehicle Mileage:
(Less Normal Commute Mileage)
Miscellaneous
All miscellaneous items require a receipt be included with the reimbursement report.
Fuel Receipts:
Select Payment
Paid by County
Paid Out of Pocket
Tolls:
Select Payment
Paid by County
Paid Out of Pocket
Hotel:
Select Payment
Paid by County
Paid Out of Pocket
Select Payment
Paid by County
Paid Out of Pocket
Remove
Meals
Per Diem Tier:
Reduced
Standard
High Cost
Include Weekends in Calculation:
Yes
No
Grand Total
Total Due Employee:
$ -.--
Total Paid by County:
$ -.--
Grand Total:
$ -.--
Department Head Signature: ________________________________________ Date: ___________________
