Form C-10 - Revised 1/1/18 (formc10)
2. Traveler Name
4. Voucher Date
LAST NAME FIRST NAME MIDDLE INITIAL 5. Appropriation Account Code
Place Time Place Time $0.545
22. 23. 24. 25. 26.
28. Total Exp.
TRAVELER CERTIFIES THAT SHE/HE IS DULY LICENSED AND CARRIES AT
LEAST THE MINIMUM AUTO LIABILITY INSURANCE COVERAGE
Division Head, Supt., Chief Date
Approved-Agency Head Date Traveler Signature Date
I certify that, in accordance with Section 12 of "An Act in Relations to State Finance", the above amount is correct
and just; that the detailed items charged for subsistence were actually paid; that the expenses were occasioned by
official business or unavoidable delays requiring the stay at hotels for the time specified; that the journey was
performed with all practicable dispatch by the shortest route usually traveled in the customary reasonable manner;
and that I have not been furnished with transportation or money in lieu thereof for any part of the journey therein
30. Purpose of Travel
This certifies that the travel shown above was required by the official duties of the
traveler named to my personal knowledge, or as indicated by records submitted to me.
If applicable, the reporting requirements of section 5.1 of the Governor's Office of
Management and Budget Act have been met.
18. Exp. Obj.
21. State License Plate Number
19. Amount 20. CFDA No.
16. Other Expenses
31. Traveler Comments/Explanations
29. Total Amount
9. Departed From 10. Arrived At
14. Lodging13. Trans
PAYMENT OF INTEREST MAY BE AVAILABLE IF
THE STATE FAILS TO COMPLY WITH THE
STATE PROMPT PAYMENT ACT, 30 ILCS 540.
1. Social Security Number