Académique Documents
Professionnel Documents
Culture Documents
2. Agency
4. Official Station
7.
Unrepresented
Management Service
Board/Commission
Member
Executive Service
Other
to
Volunteer
Other
Home Address:
Employee ID
9.
8.
Date
Time of
Departure
10.
11.
12.
Time of
Arrival
Per
Diem/
Full Day
Description
Individual Meal
Reimbursement
Breakfast Lunch
Dinner
25%
25%
50%
13.
14. Total
Lodging
(Less Tax)
15. Totals
16.
PCA
OBJ
Totals
17.
Amount
Date
18.
Miscellaneous Expenses
Fares, Private Mileage, Room Tax, Telephone,
Baggage, Other
19.
20.
21.
22.
23.
Total
PVM
Commut Reimbursed Rate per
Amount
Miles
e Miles
PVM Miles
Mile
Travelled
0.0
0.0
0.575
0.575
0.0
0.0
0.0
0.23
0.23
0.56
0.0
0.0
0.56
0.235
0.0
0.235
25. I did_____ did not _____ accept travel awards as a result of, or associated with this state business trip.
Completion of this block is mandatory. Travel expense reimbursement claims will not be processed if this block is left blank. Travel awards included,
but may not be limited to , airline frequent flyer miles and hotel or car rental frequent customer awards.
26. REASON FOR TRAVEL: (Be specific.)
27. Grand Total Amount
$
28. Travel Advance Amount
29. Amount Due Employee/State
I certify that all reimbursements claimed reflect actual 31. Signature of Employee
Conducted Training
Date
33. Approved By
34. Title
Administrator/Designee if OOS
Date
INSTRUCTIONS
Receipts for all lodging expenses claimed and for miscellaneous expenses over twenty-five dollars must be attached to the origi
copy of this form. A copy of the approved out-of-state travel authorization must be attached when expenses are claimed for out-of-st
travel. Approval and justification for reimbursements over applicable per diems must be attached. The original travel expense de
sheet should be submitted for payment. Employees should retain a copy for their records.
These instructions are intended to answer the questions that most frequently arise in the use of this form. Rules for state busine
travel are published as Chapter 40.10.00.PO of the Oregon Accounting Manual. That document contains references to the relev
Oregon Revised Statutes.
1.
17. Date: Show the month and day(s) in which the miscellaneo
expense(s) is incurred (e.g., 8/5 or 8/5-6).
2.
3.
Period: Enter the month and the year during which the
expenses were incurred. (e.g., July 2001).
4.
5.
6.
7.
8.
9.
Date: Make a separate line entry for each day of travel in the
month. Enter the date for the day of the month. Use
additional forms as necessary.
Time of Departure: Enter the time of departure. Round to the
nearest hour. When expenses are being claimed, time of
departure is required.
10. Time of Arrival: Enter the time of arrival. Round to the nearest
hour. When expenses are being claimed, time of arrival is
required.
11. Destination: Show the location where the expense was
incurred. If the expense was incurred in transit, enter En
route to (name of destination).
12. Per Diem: Enter the applicable daily meal per diem for the
travel destination. Enter the amount of individual meal
allowance amounts derived from the applicable daily meal
per diem for the travel destination when a partial day of travel
is being claimed. (e.g. first and last day of travel) These
blocks are also used by elected officials or members of
boards and commissions claiming actual and necessary
expenses per DAS travel rules.
13. Lodging: Enter the actual cost of lodging, not including room
tax (see 18 for room tax reimbursement).
14. Total Meals and Lodging: Enter the total of the amounts
shown under Item 11, or under Items 12 and 13 for each day.
22. Rate Per Mile: Enter rate per mile for private vehicles.
15. Show the total of each column at the bottom of the columns.
16. Cost Distribution: This section is for the use of the fiscal unit