NEW MEXICO INSTITUTE OF MINING AND TECHNOLOGY
NON-EMPLOYEE TRAVEL
REIMBURSEMENT FORM
Instructions: Submit completed form with original receipt(s) to the travel department (Fidel
216). All information must be completed for payment to be made. The payment will be
treated as taxable income if receipts are not provided. See the procedures document for
details on reimbursements to foreign entities.
Travel Number: ____________
Payee: Date:
Payee Address: Department name:
City: State: Dept. contact person:
Phone: Zip: Dept. phone #:
Mail check to (address): Or Hold the check for pick up
Acct. # Total Payment $
Traveler statement:
Traveler’s Soc Sec number or ITIN (if available): Name:
Citizenship declaration: I certify that I am a citizen of the country of:
If you are not a citizen of the United States, please attach copies of the immigration
documentation defined in the procedures document.
Traveler Signature: _____________________________ _______________
(Signature) (Date)
Mileage and per diem:
Date of Departure: Date of Return:
Time of Departure: Time of Return:
Odometer: Beginning: Ending:
Per Diem: Days Hours Rate: $ per day
Explain the reason for the travel:
Dept. Authorized Signature: ____________________________ Date: _________
Federal Compliance Mgr: ______________________________ Date: _________
Accounting approval: __________________________________ Date: _________
Federal Compliance Office – route here when traveler is NOT a US citizen; or when receipts are
not provided.
1099 Amount of Tax to withhold from the payment: $ _________ USD
Business Office Use only
Invoice date: Vendor #:
Invoice #: Payment date:
Updated: July 2013
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