City of Boulder - Travel Expense Form

Today's Date:

August 20, 2015

Employee Name:

Matt Appelbaum

Trip Dates:

July 18-24, 2015

Trip Destination:

Rome, Italy

BFS Coding:

10501005 710500

Trip Purpose:

Vatican Symposium - Climate Chan

DV # :

Date(s) Traveled:
Transportation:
Airfare
Personal Car Use:
# of Miles
Reimb. Rate
Mileage Reimb.
Rental Car
Parking
Taxi/Shuttle

7/18/15

7/19/15

7/20/15

7/21/15

7/22/15

7/23/15

7/24/15

$ 2,474.00

Total
$ 2,474.00
-

$
$

0.565
-

$ 0.565
$
-

$ 0.565
$
-

5.00

$ 17.08

$ 34.16

Total Transportation $ 2,479.00

$ 17.08

$ 34.16

$ 121.66

$ 121.66

$ 121.66

$ 121.67

$ 121.66

$ 121.66

$ 121.66

$ 121.67

Hotel & Other Travel Costs:

Hotel
Per Diem
Conference Reg.
Other

$ 0.565
$
-

$ 0.565
$
-

$ 0.565
$
-

$
$

0.565
-

28.65

$
$
$
$

28.65

$ 2,558.89

84.89

$
$
$
$

486.65
-

486.65

Meals (Complete only if Per Diems not used - reimbursed amount not to exceed Per Diem amount)
Breakfast
$
Lunch
$
10 44
10.44
$ 14.26
14 26
$
Dinner
$ 26.45
$ 42.98
$

24.70
24
70
69.43

Total Meals

94.13

Total Hotel & Other

10.44

$ 26.45

$ 14.26

$ 42.98

Total Transportation, Hotel & Other Travel Costs (including Meals, if applicable)
Less Pre-Payment to Employee
Amount Due To/(From) Employee

$ 3,139.67
$ 3,139.67

Employee certification: I certify that I actually incurred the expenses for which reimbursement is claimed while on
official City business and not for personal purposes and that the amounts have not and will not be reimbursed to me
from any other source. I have attached receipts to this form for those expenses where required.
If mileage reimbursement for use of my personal car is claimed, I certify that I maintain, in my vehicle, proof of
current automobile liability insurance coverage in compliance with the State of Colorado Motor Vehicle Financial
Responsibility Act. I understand that the minimum amount of insurance required by this Act is $25,000 per person
and $50,000 per accident for bodily injury or death and $15,000 for property damage. I also understand that my
personal insurance is the sole coverage for any casualty or liability claims.
Supervisor's approval: I have authorized the travel described above, reviewed the expenses incurred and consider
them reasonable and request that the amounts involved be charged as indicated in the BFS coding shown above.

Employee Signature

Supervisor/Dept. Head Signature