Purpose of Travel:
Traveler Comments/Explanations:
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 Officeof Management and Budget Act
have been met.
_______________________________________________________
Fiscal Agent Date
_______________________________________________________
Purchasing Date
I certify that, in accordance with Section 12 of "An Act in relation to State Finance," the above amount is correct
and just; that the detailed items charged within are taken and verified from memorandum kept by me; that the
amounts charged for subsistence were actually paid, and the expenses were occasioned by official business
or unavoidable delays, requiring my stay at hotels for the time specified; that I performed the journey 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. In consideration of the
payment in full by the Board of Trustees of Western Illinois University, I do hereby irrevocably release and
forever discharge the Board of Trustees of Western Illinois University and its members from all claims,
demands, and causes of action which the undersigned, may have now or in the future for any and all loss or
expenses resulting from, arising out of, or in any way connected to the aforesaid reimbursement.
_________________________________________________________________________________
Traveler Signature Date
_________________________________________________________________________________
Vice President (if $1,000 or over) Date
Date ________________________
Cost Center Name ___________________________________________________________________ Cost Center # ____________________ -
4550
Encumbrance TC _________ Exp Class _______
Payee ________________________________________________________________________________ FEIN/SSN _________________________________
Address _________________________________________________________________________________________________________________________
Requested By ____________________________________________________________________________ Phone Number ___________________________
TC ______ Ref ______ Desc_____________________________________________ Date ______________ Amt ________________
8. Date 9. Departed From 10.Arrived At 11.Auto
Mileage
@_____
12. Auto
Reimburse-
ment
13. Trans 14.
Lodging
15 Meals
or/
Per Diem
16. Other Expenses
Place Time Place Time Item Amount
1291 SUBTOTALS--
1292 TOTAL AMOUNT--
WESTERN ILLINOIS UNIVERSITY
Non-Employee Travel Voucher
00
Voucher
Number
Vendor Number
President/Vice President (Regardless of Amount)
