Relocation Expense Reimbursement Request
Employee Name: __________________________________________________________________
Contact/Mail Address: ______________________________________________________________
Telephone/Cell: ______________________________ Office: _______________________________
Department: _____________________________ Job Title: _________________________________
Maximum Budget Allowed: __________________________________________________________
Chart String(s) where expenditures occur:
Dept__________Fund ________ Acct________ Program________ Class________ Project________
_________________________________________________________________________________
Supervisor Approval Date
Expense Category
Payment
to
Employee
Payment
to
Third
QME
HR USE
NME
HR USE
Packing/Crating/Insurance
Commercial Moving Company
In transit storage (30 day limit)
Auto Mileage (x IRS guidelines) or
Gas Purchase
I certify the expense listed were incurred by me as a result of my relocation from ___________________
to___________________ which is a commuting distance greater than 50 miles one way than the
commuting distance between my former residence and my former work location. I agree that in the event
of voluntary separation or termination for cause, within the first year of employment I will repay the
University all relocation cost unless the University waives repayment.
_____________________________________________________________________________________
Employee Signature Date
