MILES
Rate
BREAKFAST
ACTUAL TOTAL
Y
N
Y
N Y
N
Y
N
BUD FY
LINE
01
02
03
04
05
06
07
08
09
10
LUNCH
DINNER
YEAR
PERSONAL VEHICLE
MEALS
Attach supporting documentation
to the back of this form
TP
STATE OF IOWA
TRAVEL PAYMENT
OFFICIAL DOMICILE
OF
TRAVEL
If other, specify here
NORMAL JOB DUTIES
CONFERENCE/SEMINAR
OTHER (specify to right) ------->
LODGING
TRANSPORTATION
AND
OTHER EXPENSES
TRAVEL
TIME
NAME AND HOME ADDRESS ALTERNATE ADDRESS (send warrant to)
ACCOUNTING USE ONLY-REFERENCE ALL OTHER RELATED DOCUMENTS
MM/DD
LEFT
RETURNED
FROM (RT = Round Trip) TO
CHARGE
ACTUAL TOTAL REIMB TOTAL REIMB TOTAL
DOCUMENT TOTAL
TOTALS
F - PHONE
I - INTERNET
L - LAUNDRY
LESS Travel Advances
DIRECT DEPOSIT?
WARRANT TO ALT ADDR?
CLAIMANT'S SIGNATURE
DATE
TRAVEL APPROVAL
(SUPERVISOR'S SIGNATURE)
P - PARKING
R - REGISTRATION
S - SUPPLIES
I CERTIFY THAT THE ABOVE EXPENSES WERE INCURRED AND THE AMOUNTS ARE CORRECT
AND SHOULD BE PAID FROM THE FUNDS APPROPRIATED BY: CODE OR CHAPTER SECTIONS:
LESS Agency Paid Expenses
TRAVEL DEPARTMENT AUTHORIZATION (TDA) NUMBER
Reimbursment Requested
CLAIMANT'S CERTIFICATION
DEPARTMENT CERTIFICATION
TITLE
DEPARTMENT TO BE CHARGED
If other, specify here
EMPLOYEE'S VENDOR
CUSTOMER NUMBER:
CHECK IF BOARD OR COMMISSION MEMBER
I CERTIFY THAT THE ITEMS FOR WHICH PAYMENT/REIMBURSEMENT IS CLAIMED WERE FURNISHED FOR STATE
BUSINESS UNDER THE AUTHORITY OF THE LAW AND THAT THE CHARGES ARE REASONABLE, PROPER, AND
CORRECT, AND NO PART OF THIS CLAIM HAS BEEN REIMBURSED OR PAID BY THE STATE, EXCEPT ADVANCES
SHOWN, AND I UNDERSTAND THE ROUTINE USES OF THIS FORM.
COMMUTING MILES EXCLUDED?
TRAVEL INCLUDES VICINITY MILES?
DOC TYPE
DOC NUMBER
DOC DATE
ACCTG PRD
ADDR
OVERRIDE Y/N
VENDOR CUSTOMER NUMBER
DOC TOTAL
TP
EMPLOYEE VENDOR CUSTOMER NUMBER
AMOUNT
FUND DEPT
UNIT /
COST CENTER
SUB UNIT OBJT SUB OBJT
TP04017PD
TP
AUDITED BY PAID DATE
DOCUMENT TOTAL
WARRANT #
DOC #
DATE PAID
LESS Travel Card Payments
ROUTINE USES OF THIS FORM ARE TO FULFILL IRS REQUIREMENTS, IDENTIFY INDIVIDUAL CLAIMS FOR PUBLIC INSPECTION, PROVIDE THE STATE
VEHICLE DISPATCHER INFORMATION, AND TO PREPARE ANNUAL SALARY BOOK
EXPENSE
A - AIR
B - BAGGAGE
C - CAB/BUS
T - TOLLS
U -POSTAGE/SHIPPING
O - OTHER ------------>
STATE VEHICLE
PASSENGER
DOC #
DATE PAID
DOCUMENT NUM
BE
R
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2015 Grand Ave, DSM
Personal Vehicle Use Example
4225 Birch Ave
Cumming, IA 50061
2018
11/05
09:00 am
03:00 pm
2015 Grand to Ames High School (RT)
77
0.39
30.03
P
2.50
11/06
07:00 am
Home to Burlington High School
173
0.39
8.00
15.00
23.00
23.00
72.80
72.80
11/07
04:00 pm
Burlington High School to Home
173
0.39
67.47
67.47
5.00
8.00
13.00
13.00
11/09
07:00 am
04:00 pm
home to Clark Comm High School (RT)
34
0.39
13.26
457
178.23
5.00
16.00
15.00
36.00
36.00
72.80
72.80
2.50
289.53
0.00
0.00
0.00
289.53
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Employee's e-signature here
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Supervisors e-signature here
289.53
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signature
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signature
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77 miles roundtrip
Since the trip started and ended at the domicile (2015 Grand) no commuting miles are deducted.
Attach meal & hotel receipts here
Since the employee went
into "travel status" due to the overnight stay, all miles driven are reimbursable
Since the trip started and/or ended at the employee's home address, all miles driven are considered,
then a deduction for normal commuting miles must be made.
66 mile round trip less 34 normal commute miles = 32 reimbursable
Normal commute miles are maintained by accounting using Google maps
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