Document #
TRAVEL EXPENSE REIMBURSEMENT REQUEST FOR NON WORKERS AS300-NW
Traveler Contact
Dept Phone
LSU ID E-mail
Destination
Travel Expenses Paid by LaCarte or CBA (not included in this reimbursement)
Date
Section A Mileage Reimbursement (Must be documented by odometer reading or attach web-based mileage calculation)
Date
A Subtotal
Section B Travel Expenses Paid with Personal Funds - Airfare, Auto & Other (not paid via LaCarte or CBA)
Date
Vehicle Rental/Gas
B Subtotal
Section C Travel Expenses Paid with Personal Funds - Meals, Lodging & Other (not paid via LaCarte or CBA)
Breakfast
Lunch Dinner
C Subtotal
Address 1
Address 2
City, State, Zip
Country
Cash Advance #
Gift Grant
Rev 06/16
Page _____ of _____
Purpose of
Travel
Submit by the 15th of the month following completion of travel.
Date
Time from
Domicile
Time to
Domicile
MEAL PER DIEMS
Lodging
Parking
Tolls
Baggage
Tips
($1/bag)
Business
Calls/
Internet
Amount
All other forms of
Transportation
Total - All Pages (Sections A, B & C)
TOTAL DUE *
Additional Worktags
Amount
FOR ACCOUNTING SERVICES USE ONLY
PO#
Less Cash Advance
Expense
Registration
Description
Amount
Shuttle and
Taxi
Airport Parking
Airfare
Luggage
Expense
Registration
Odometer Beginning*
Airfare
Luggage
Vehicle Rental/Gas
Hotel
Airport Parking
Other/Miscellaneous
Amount
Rate
Odometer Ending*
Total Miles
Amount
Other/Miscellaneous
Other/Miscellaneous
Description (attach original itemized receipts)
Project
Total This Page - (Sections A, B & C)APPROVALS
I certify that the expenses claimed for reimbursement on this request were paid
Spend Category
Audited by
& Date
with my personal funds and incurred on University business travel.
Traveler Date
FDM WORKTAGS
***Current mailing address is required***
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