NORWALK COMMUNITY COLLEGE
EMPLOYEE VOUCHER – TRAVEL AND OTHER
FOR EXPENSES INCURRED IN THE SERVICE OF THE STATE OF CONNECTICUT CO-17XP
REV. 7/2019
Traveler Name: __________________________________________________________________
Traveler Address: ___________________________________
_______________________________
EMPLOYEE EXPENDITU
RES
PAYEE CERTIFICATI
ON AND APPROVALS
I affirm the reimbursement claims herewith are just and the travel indicated was officially necessary. I further affirm that all
applicable obligations incurred by the state on my behalf, such as family travel and associated expenses, have been prepaid, by
me, in full. I certify that the services have been performed and the expenses incurred as stated above.
Payee’s Signature:
Date:
Supervisor’s Signature:
Date:
Dean’s Signature:
Date:
PLEASE DO NOT WRITE IN THE SPACE BELOW.
FORWARD FORM TO HUMAN RESOURCES, ROOM E304, FOR PROCESSING.
Date Approved:
Amount Approved:
Chief Operating Officer's Signature:
TA Number
__________
AMOUNT
FUND
ORG
PROGRAM
Travel
To:
CARRIER
Air/Rail/Bus/Taxi
REGISTRATION
MEALS
LODGING
MISC.
(Parking/Tolls/Tips
etc.)
Travel by Automobile:
State Vehicle Personal Vehicle
Number of Miles:
@
Total Amount:
Subtotals
Less: Prepaid by Pur. Req/PCard:
I certify that the amount stated here was given to me as an advance
against the amount of travel and other expenses shown herein as due me.
Amount of Advance
(if applicable):
Total Page 2
(if applicable):
Reimburse Total:
/mi
Travel Dates:
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