Home Station Per Diem Reimbursement Request – SDCL 3-9-2.2
When Application and Authorization sections are completed, please submit the original to:
State Board of Finance - Office of Secretary of State
Capitol Building - 500 E Capitol Ave - Pierre, SD 57501
Phone: 605-773-3537
PLEASE NOTE: The request and all supporting documentation must be received in the Office of the Secretary of
State no later than 5:00 p.m. CT eight days prior to the Board of Finance meeting on the third Tuesday of the
month. Documentation received after that time will be processed at the next Board of Finance meeting. All
documentation MUST comply with Bureau of Human Resources policies regarding protection of personally identifiable
information.
Application
Date: ________________________________ Agency: ______________________________________
Agency Address:
Agency Phone Number:
Employee Requesting Reimbursement:
Total Amount of Reimbursement:
Date(s) of Expense:
Event Leave Time: ____________________ Event Return Time: _____________________________
Explanation of official business performed:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I hereby request authorization and approval for reimbursement of expenses, set forth in the voucher attached hereto, that were
incurred while conducting state business at my headquarters station or place of residence. I certify that the event extended
entirely through a meal time without interruption and included a meal provision for which I was billed. I declare and affirm
under the penalties of perjury that this claim has been examined by me, and to the best of my knowledge and belief, is in all
things true and correct.
Signature of Employee Date
Authorization
I hereby certify that the above employee was authorized to incur the claimed expenses at their headquarters station or place of
residence while performing necessary duties of their employment on behalf of the State of South Dakota. I attest that the
employee’s participation in the event was in the furtherance of state interests.
Name of Department/Office Head Position/Title of Agency Official
Sig
nature of Department/Office Head Date
State Board of Finance Approval
Approval Date:
Signature of Secretary, State Board of Finance
Note: When completed, attach the original form and receipts to voucher to be sent to the State Auditor’s Office.
