TRAVEL EXPENSE / PAYMENT VOUCHER FORM
To be used in conjunction with direct pay and credit card reconciliation.
Attach original receipts that total to reimbursement amount.
Z#: Dep’t. Name:
Fund: Org: Account: Program:
All Itemized Expenses (Chronological)
(*If Normal Work Day, Deduct Normal Commutation Mileage/Official Station-RSC)
Total Net Miles @ .575¢ Mile
LESS UNIVERSITY PCARD EXPENSES Total
LESS NON –REIMBURSABLE EXPENSES $
TOTAL AMOUNT DUE FOR REIMBURSEMENT $
If a negative total amount is due, please submit check payable to the University with reconciliation.
Please use colored ink for signatures so that originals may be distinguished from copies.
I CERTIFY THAT ALL OF THE CHARGES INCLUDED IN ABOVE AMOUNT WERE NECESSARY AND INCURRED FOR OFFICIAL UNIVERSITY
BUSINESS I CERTIFY THAT ANY EXCESS FUNDS HAVE BEEN REIMBURSED TO THE UNIVERSITY AS REQUIRED.
PAYEE SIGNATURE: DATE:
APPROVER SIGNATURE: DATE:
Check If Non-Workday Travel